Abstract
Project Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth (ACTIVITY) is a community-based group randomized intervention trial focused on disadvantaged youth (aged 10–19 years) residing in 14 low-income communities (slums and resettlement colonies) in Delhi, India. This article discusses the findings of Focus Group Discussions (FGDs) conducted to inform the development and test the appropriateness of Project ACTIVITY’s intervention model. The findings of the FGDs facilitated the understanding of factors contributing to increased tobacco uptake and cessation (both smoking and smokeless tobacco) among youth in this setting. Twenty-two FGDs were conducted with youth (10–19 years) and adults in two urban slums in Delhi. Key findings revealed: (i) youth and adults had limited knowledge about long-term health consequences of tobacco use; (ii) socio-environmental determinants and peer pressure were important variables influencing initiation of tobacco use; (iii) lack of motivation, support and sufficient skills hinder tobacco cessation and (iv) active involvement of community, family, religious leaders, local policy makers and health professionals is important in creating and reinforcing tobacco-free norms. The results of these FGDs aided in finalizing the intervention model for Project ACTIVITY and guided its intervention development.
Introduction
Socioeconomic disadvantage is inextricably linked to risky behaviours which influence health and tobacco use is one such behaviour [1–3]. In India, 60–80% of children and adolescents live in low resource settings [4], and it is already established that youth from low socioeconomic backgrounds are more likely to engage in risky health behaviours when compared with those from higher socioeconomic background [5], including tobacco use [6]. Evidence suggests that in India tobacco use starts in childhood and adolescence, sometimes as early as 10 years of age [7], and therefore, this vulnerable group should be especially targeted in tobacco control programmes.
Research from developed countries [8–16], and also from India [17], suggests that multiple social, psychosocial (perceptions, knowledge, intentions) and environmental determinants influence the onset and progression of tobacco use during adolescence. These proximal and distal influences lead to higher use of tobacco products among youth belonging to low socioeconomic status (SES) [6, 17]. Tobacco use in this group is also influenced by individual, cultural–environmental and social-contextual factors [12]. Prevention through early intervention during adolescence is required before it becomes an addiction [18]. Tobacco prevention and cessation programmes for such youth need to address multiple individual and contextual risk factors in order to be effective [19].
It is essential to obtain the perspectives of youth and adults residing in disadvantaged settings with respect to the determinants of tobacco use. Project Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth (ACTIVITY) funded by the Fogarty International Centre at the National Institutes of Health, USA, is a community-based, group randomized intervention trial focused on disadvantaged youth (10–19 years) residing in 14 low-income communities (slums and resettlement colonies) in Delhi, India. Seven communities were randomly assigned to receive a 2-year intervention, while other seven communities served as the control group (and received free eye care and dental care).
In November–December, 2008, a qualitative research study was conducted to explore contextual influences that enable initiation of different forms of tobacco use among youth (e.g. cigarette smoking, smokeless tobacco, bidi [a local hand-rolled cigarette] smoking), and their perceptions about tobacco cessation using Focus Group Discussions (FGDs). The main purpose of the FGDs was to inform intervention design and to test the appropriateness of all components of Project ACTIVITY’s intervention model (refer Fig. 1). The intervention model had been developed building on this research group’s earlier experience and existing literature on tobacco control among youth [20, 21, 22].
Fig. 1.
Intervention model for Project ACTIVITY.
Methods
Twenty-two FGDs were conducted in two urban low SES communities in Delhi, each community comprised of a slum and resettlement colony. A slum (also called ‘Jhuggi-Jhopri’) is a community of roughly built houses or shelters usually made of mud, wood or metal having a thatch or tin sheet roof covering them. A resettlement colony includes households that have been resettled from their original settlements, which are often slums. The government provides more infrastructures (such as water and electricity) in these colonies, and the houses there are made of more permanent materials like concrete [23].
The two communities were different from the communities selected for the main study and were sociodemographically identical to them. Separate FGDs were conducted with adult males and females (6FGDs) (aged 22–60 years) and youth (16FGDs) (both boys and girls, aged 10–19 years), residing in these communities. Each group included 8–10 participants. A total of 46 adults and 148 youth participated in this study.
The researchers’ earlier experience of working in the communities encouraged them to reach as many groups of youth and adults as possible to get a wider perspective [24]. The youth group comprised of boys and girls in the age group (i) 10–14 years, school going/non-working (n = 38 participants) and non-school going/dropouts/working (n = 40 participants); (ii) 15–19 years, school going/non-working (n = 35 participants) and (iii) 15–19 years, non-school going/dropouts and working (n = 35 participants). Adult participants (22–60 years), both males and females, were further subdivided into (i) community leaders (n = 11 participants), (ii) male community residents (n = 17 participants) and (iii) female community residents (n = 18 participants).
Participants were recruited in this study using snowball sampling procedure [25], with the help of a local non-government organization (NGO) working in the respective communities. Informed consent was obtained from the participants before they were recruited for the FGDs. The discussions were conducted at a scheduled time and place, as per the convenience of the participants and at a venue within the community. The confidentiality of responses was assured. Protocols were approved by the ethics boards, i.e. Independent Ethics Committee, Mumbai, in India and Institutional Review Board, at the University of Texas, USA.
FGD questions
Separate FGD guides were used, for the youth and adults (Tables I and II). The guidelines comprised of a list of semi-structured questions in English, and translated into Hindi, the local language of the participants. The questions were asked to identify various intra-personal and social–environmental determinants influencing onset of tobacco use, context that enables uptake and continued use of different forms of tobacco and determinants that can motivate users to quit tobacco use, in accordance with the conceptual model of Project ACTIVITY.
Table I.
Guidelines for focus group discussions with adult community leaders
| Intrapersonal factors | |
|---|---|
| Knowledge | Skills |
| Do you think that tobacco use is a cause of concern? Probe: Is it increasing? | Is it possible for you to convince young people in your community to not start using tobacco? How? |
|
Could you convince young people in your community to quit using tobacco? How? |
| Are you aware of any existing law related to tobacco control? | What skills do you think young people in your community need to protect themselves from tobacco use? |
| Social environmental factors | ||
|---|---|---|
| Role models | Opportunities | Support |
|
What would be the most effective way(s) of informing youth about the problems associated with tobacco use? | Do you think that acknowledging and recognizing the attempt to quit tobacco by an individual would motivate other tobacco users to quit using tobacco? |
| Can these role models help motivate these youth to keep away from and/or quit using tobacco? How? |
|
What kind of support should be provided to an individual who is making an attempt to quit using tobacco? Probe;
|
Table II.
Guidelines for focus group discussions with community youth
| Intrapersonal factors | ||
|---|---|---|
| Knowledge | Values, meanings, beliefs | Skills |
|
Why do you think young people of your age in your community start using tobacco? | Is it possible for you to convince other young people, of your age in your community, to not start using tobacco? How? |
|
Why do you think young people of your age in your community who use tobacco might find it difficult to quit? | Could you convince other young people of your age in your community to quit using tobacco? How? |
| Are you aware of any existing law related to tobacco control? | ||
| Social environmental factors | |||
|---|---|---|---|
| Norms | Role models | Opportunities | Support |
How many young people of your age in your community consume tobacco? Probe;
|
Do you think youth have role models? Who are the role models for young people of your age in your community? Probe;
|
What would be the most effective way(s) of informing youth about the problems associated with tobacco use? | What kind of support should be provided to initiate and/or sustain these ways of motivating youth to quit tobacco use or avoid starting it? |
| How do these role models influence these young people’s tobacco use? | What would be the most effective ways of motivating youth to quit tobacco use and/or avoid starting or experimenting with it? That is, what steps should be taken in the community to reduce youth tobacco use? Probe;
|
||
| Can these role models help motivate these youth to keep away from and/or quit using tobacco? How? | |||
The questions about intra-personal factors were asked to elicit participants’ responses about knowledge related to tobacco use and control; types of tobacco use, their values, meanings and beliefs regarding tobacco use; their skills to refuse offers of tobacco as well as advocacy skills to promote tobacco control in their communities and finally, their motivation to quit tobacco use and intentions to refrain from tobacco use. Questions were also asked to get an insight into the reasons to use or not to use tobacco, as well as understanding the reasons for a person’s inability to quit tobacco use. In addition, resistance and advocacy skills of the youth were also discussed.
A second set of questions pertaining to socioenvironmental factors were asked to generate a discussion in each group about opportunities, barriers, role models and social norms with regard to tobacco use, cessation and tobacco control. Furthermore, participants’ responses were elicited about ways in which social support could be increased for youth to abstain from and/or quit tobacco use, as well as strategies for better enforcement of tobacco control policies.
Data collection and analysis
A team of two moderators assisted by two note-takers conducted the FGDs. The moderators were trained social scientists with expertise in qualitative research. Moderators explained the purpose and procedure of the FGD to the participants. Each FGD lasted for about 60 min. The note-takers were responsible for audio-taping the discussions and subsequently for transcribing the tapes and taking notes during FGDs. The transcribed tapes were checked against the notes of the note-takers and then translated into English. This ensured the reliability of the data used for the analysis. Incentives included refreshments for all participants in recognition of their time. All transcripts were independently reviewed by two members of the research team in Delhi and University of Texas to identify recurrent themes across individuals and groups to minimize the risk of subjectivity and established validity. Each transcript was read several times and data were coded and put under two heads, i.e. intra-personal and socioenvironmental factors to collate with the intervention model for ease of interpretation and discussions. NVIVO software was used to develop the coding scheme [26].
Results
The results from the FGDs with youth and adults (community residents and community leaders) are presented below under two main categories: intra-personal determinants and socio-environmental determinants. These categories are congruent with our initial intervention model (Fig. 1). The participants represented a mix of literate and illiterate, tobacco users and non-users. All adult males were working, some of them had their own shops and others were in private jobs. Most of the females were illiterate housewives engaged in petty jobs to add to their family income. Sometimes the youth took up odd jobs, but often they had no jobs and plenty of free time.
No major differences emerged in results from the youth FGDs by school-going status, age group and gender, thus findings are pooled together for all youth. From adult FGDs also no major differences emerged in results by age group and gender and findings are pooled together for all adults. However, these discussions generated interesting findings specific to socio-environmental determinants, which are presented under the respective thematic category and identified as being from adult FGDs. Although findings are presented under distinct thematic categories for ease of interpretation and discussion, these are not very strict definitions because participants often spoke about multiple themes simultaneously.
Intra-personal factors
Perception about prevalence of tobacco use
Almost all the participants (youth and adults) were concerned about a rise in tobacco use in their community. Boys talked about the use of chewing tobacco by other boys, cigarette smoking by adult males and bidi smoking by relatively older females. Both adult males and young boys (10–14 years) pointed out that tobacco use by girls was less prevalent. Females felt that tobacco use by adult males sets the wrong example for youth.
Availability of tobacco products
Nearly all the youth were aware of the multiple forms of tobacco products available in Indian markets. In response to questions about specific types of tobacco products, smokeless forms such as chewing tobacco (locally known as gutkha) were mentioned more often than smoked forms such as cigarettes or bidis. The youth also identified several common brands of gutkha available in their communities such as, ‘Rajdarbar’ and ‘Chaini Khaini’. However, when probed further, although most of them were aware that these were chewing tobacco product, few of them were unaware about the contents of commonly consumed gutkha products. In addition, youth also talked about other prevalent forms of drug addiction, i.e. use of alcohol, marijuana, smack (slang for heroin) and glue. Participants (youth and adults) reported that people often switch between various tobacco products (e.g. switching from smoking to chewing tobacco or vice versa). Furthermore, the majority of youth indicated that tobacco products were easily accessible and available to young people in their communities.
Knowledge of consequences of tobacco use
A majority of the youth were aware about the harmful health effects of tobacco use. Participants talked about cancer, lung disease, mouth ulcer, heart problems, teeth problems, tuberculosis, asthma, disturbed sleep and gastric problem but could not differentiate between the short-term and long-term health effects of tobacco use. One of the 15 - to 19-year-old non-school going girls noted, ‘His [gutkha user’s] health is getting worse, he does not eat food properly as he cannot open his mouth completely.’ Social problems such as petty crimes (thefts), gambling, borrowing money, domestic violence and begging were also noted to be associated with tobacco use. The majority of the participants (youth and adults) were aware of the economic consequences of tobacco use including diversion of financial resources that could be better used such as spending on school fees. A 10 - to 14-year-old non-school going boys said, ‘if there is some problem at home, there is no money to give at home. Father consumes gutkha, that’s why there is no money. All that money is spent on gutkha.’
Knowledge about quitting tobacco
The majority of participants (youth and adults) were aware that tobacco use was addictive or habit-forming and that it was necessary for tobacco users to get help or ‘treatment’. A 10 - to 14-year-old non-school going boy noted, ‘Urge for tobacco is similar to that of a drug. Like when someone has fallen sick and says, “Just bring my medicine.” They [youth] want cigarettes like that, too. They get the urge for tobacco. They need treatment.’
Few youth were aware of the health benefits of quitting tobacco. On the contrary, some participants (youth and adults) stated that stopping tobacco use itself could cause problems such as gastro-intestinal problems. An adult female said, ‘He [tobacco user known to her] says that if some people are smoking daily and quit, they get gastric trouble. So, they start again.’
Values, meanings and beliefs
Reasons to use tobacco
A majority of the youth-stated tobacco use among friends, peers, parents and other family members was an important and influential factor for initiation of tobacco use. As mentioned by a 10 - to 14-year-old non-school going boy, ‘First I used to consume sweet paan [betel leaf]. Then, they [my friends] told me to consume tobacco paan. I vomited. They told me, to have Kuber (chewing tobacco brand) I had some and again I vomited.’
Tobacco use was also considered a remedy to reduce stress and headaches; a means for enjoyment and an opportunity to explore new things. Another important reason stated by most youth was the ‘style’ factor. Some participants (youth and adults) mentioned that young boys often try to impress girls by smoking and likewise, girls try to imitate boys smoking to be seen as ‘equal’ to them.
Reasons not to use tobacco
Other than an acknowledgement of the negative health effects of tobacco use, youth and adults indicated the economic loss associated with tobacco use as an important reason to not buy and use tobacco products. One adult male said, ‘A cigarette packet costs 28 Rupees [0.60 US$]. I know this is wastage of money, this money can be spent on children and other needs.’ Youth felt that prevention efforts should be targeted to reinforce reasons not to use tobacco among non-users because this would be easier to accomplish than to get tobacco users to quit.
Reasons for inability to quit
Some youth and adults were of the opinion that quitting was just not possible, whereas some believed that it could only be achieved through one’s strong self-determination and will. As a 10 - to 14-year-old non-school going girl put it, ‘He does not want to quit. It is very difficult to quit.’ Reasons cited for inability to quit included lack of knowledge about health effects of tobacco, withdrawal symptoms related to quit attempts, lack of motivation or willingness to quit, lack of professional advice and support, resistance to counselling (when available) and reinforcement to use tobacco from peers and other social role models. Interestingly, several youth expressed that use of force, threats or physical punishment would be the only effective way to make children stop using tobacco. There was some discussion about difficulties with making adults quit tobacco use and how adults needed to be convinced to quit before approaching youth. Finally, youth also stated that those who tried to quit would often switch to alternate tobacco products (e.g. to gutkha from smoking) or other substances (e.g. alcohol).
Skills
Resistance skills to refuse tobacco
Several youth expressed that they were unable to resist peer pressure to use tobacco products and/or shift to alternate forms of tobacco use. There was a general feeling of helplessness about being able to refuse tobacco offers from peers or others. For example, a 15 - to 19-year-old school going boy said, ‘If you go to a marriage party and someone offers you [tobacco], then people cannot ignore easily.’
Advocacy skills to promote tobacco-free environment
There was a general consensus that it would not be possible for youth to advocate for reducing tobacco use or for creating tobacco-free environments in their communities. The youth indicated that most often tobacco users did not like others telling them to stop smoking or chewing. They expressed lack of skills to motivate community members to stop tobacco use or to work with local organizations on tobacco control measures. However, some of them did express ideas on how they could advocate for tobacco control. A 15 - to 19-year-old non-school going girl said, ‘First one can try from one’s own home, and then approach neighbours’ houses. It should begin from an individual level effort.’ Some of the adult participants explained that although an overall desire to reduce the tobacco problem in their communities was present, people were too busy with their own lives to get involved in community initiatives.
Motivation for tobacco initiation
Intent to initiate tobacco use
Most of the youth noted that responsible role modelling from peers and family would be essential for any attempts to reduce intent of young people to initiate tobacco use. One 15 - to 19-year-old non-school going girls brought out the importance of non-smoking parents and elders who smoked when she said this, ‘If parents do not consume tobacco at home, they would be able to better convince their children not to use. If parents use these things, then it will surely affect their children.’
Intent to quit tobacco
Similar to the construct on resistance and advocacy skills, the majority of participants (youth and adults) were pessimistic about change in the behaviour of tobacco users. Some youth suggested that to encourage stubborn tobacco users to make a quit attempt, ‘we should approach them when they are sick due to tobacco use and remind them at that point about the harms of tobacco use to their health.’
Socio-environmental factors
Opportunities and barriers
The discussion on this topic aimed to get participants’ feedback on the ways in which Project ACTIVITY could encourage the community youth to learn about tobacco control policies and help in enforcing them.
Existing knowledge about tobacco control policies
The majority of participants, including youth and adults alike, were somewhat aware about current tobacco control laws in India. The laws mentioned by participants included a ban on smoking in public places and related fines; a ban on sales to and by minors, along with display of this law on boards at point of sale; a ban on tobacco product sales around educational institutions and warning labels on tobacco packs. For example, a 10 - to 14-year-old non-school going boy replied, ‘It is prohibited to sell bidis and cigarettes to children below 18 years of age…. [It] is written on the shop where cigarettes and bidis are available.’
Although there was a general awareness of these laws, not all participants were aware of details such as complete list of public places where smoking is prohibited or the distance (100 yards) around educational institutions where tobacco products cannot be sold. More importantly, almost all participants mentioned that although the laws exist, enforcement was very poor. According to the community leaders and residents, ‘The boards say that tobacco cannot be sold to children below 18 years of age, but if you send a six year old child, they will sell it to them…. There is a board outside the [name of a school] but just beneath the board there is a shop.’
Opportunities to learn about and strengthen tobacco control policies
Youth and adult participants had several suggestions which included utilizing games or sports events to reinforce support for tobacco control; encouraging local shopkeepers to sell healthier commodities instead of addictive substances such as tobacco and using media to show children advertisements against tobacco use and promoting role models that speak against tobacco. Some youth and adult participants suggested that local religious and community preachers would be good role models to speak against tobacco. A 10 - to 14-year-old school going boy said, ‘Send them to Jamat [religious school for Muslim children]. There, nobody is allowed to do any wrong thing. If Qazi sahib [religious teacher at Jamat] says not to consume tobacco, then they [children] will listen and not take it…. Yes, they [Hindus] also follow what their gurus [preachers] say.’
Youth participants also made suggestions about the Government’s role in the endeavour, such as banning sales of tobacco products, making these products expensive and placing enforcement officials like police in the communities.
Community leaders and other adult residents made some additional suggestions. Schools were a favoured venue, with participants recommending inclusion of tobacco control education in schools through curricula, games and other interactive sessions. Furthermore, the need for engaging health professionals to address tobacco control through educational camps and cessation clinics was emphasized. Community leaders felt that residents in their communities needed to be empowered through training to support Governmental initiatives for tobacco control and suggested that one way to do this would be training of selected youth and adults by NGOs.
Role models
Parents
All participants, including youth and adults, emphasized the significant influence of parents and other elders at home on young people to experiment with and initiate tobacco use. Another key factor was the detrimental effect of parents sending children to local shops to buy tobacco products—this was considered to be sending the wrong message to children. A 15 - to 19-year-old non-school going girl said, ‘the biggest thing is that they send children for buying such things. So, the child thinks that if parents are using, they can also use.’ Participants indicated that they would like parents and family elders to educate and share positive ‘tobacco-free’ life experiences with them.
Community leaders
Both the youth and adults indicated that teachers, community leaders, religious preachers and law enforcement officials would be important social role models. It was suggested that teachers should not send students to buy tobacco products for them and law enforcement officials should not be seen consuming tobacco. A community leader stated, ‘Policemen also use cigarettes on the street. Doctors also use cigarettes.’ Not many participants felt that film stars and sports persons would be effective role models as several such persons themselves consumed tobacco products and this was widely seen in media. It was felt by the groups that any effect of using such celebrities was likely to only have short-term benefits. Instead, they recommended that elders in the community and local politicians should set an example first by quitting tobacco use and supporting healthy habits.
Social norms
Age of initiation and perceived prevalence
Most participants including youth and adults said that tobacco use begins as early as 6–10 years of age. Most believed that in the community nearly 50% young boys and 20% young girls used tobacco. With regard to questions of the burden of tobacco use within specific demographic sub-groups, most groups agreed that adults, males and boys consumed more tobacco than children, females and girls, respectively. However, girls were perceived to consume more smokeless tobacco products and older females were also reported to be bidi smokers. With regard to young tobacco consumers, it was indicated that non-school going children, homeless and street children were more likely to be tobacco consumers. Some participants also pointed towards higher tobacco use among immigrant communities from Bangladesh. Similarly, people who worked as rag-pickers or as drum players (for weddings and other festivities) were perceived as being more likely to be tobacco users when compared with others in the community.
Normative beliefs and normative expectations
Most of the youth participants seemed to suggest that unlike adult tobacco use, tobacco use by the youth was not socially acceptable. It was suggested that youth usually smoked or chewed tobacco in secret, never in front of their elders, as it is not looked upon favourably by parents, family or other community elders. A 15 - to 19-year-old school going girl said, ‘They [boys in our street], do not smoke in front of their parents, but smoke bidis on their terrace [roof top].’ Similarly, a 15 - to 19-year-old non-school going boy said, ‘Generally, people do not use tobacco in front of elderly persons.’
Perceived access
It was noted that youth had easy access to cigarettes, bidis and chewing tobacco products. A 10 - to 14-year-old school going boy observed, ‘Yes, it [tobacco] is easily available even in smaller shops. Alcohol is not available in every shop, but this is available at every small shop.’ Young people in these communities borrowed money from friends or even stole money in order to buy tobacco products. Some participants indicated that when parents send their children to buy tobacco products, children also get easy access to these products. A 15 - to 19-year-old girl (whose family ran a local tobacco shop) said, ‘If we don’t give him [tobacco], then he will buy from some other shop. They say that they are buying it for their uncle.’ Some youth explained that they had seen children in the neighbourhood pick up partially smoked cigarettes or bidis thrown by their parents or others, and smoke these too.
Strategies to reduce tobacco use among youth
Social support
Some of the suggestions to increase social support included the need for support from health professionals at cessation clinics; encouraging an active role of teachers and access to treatment for addiction. It was also noted that homeless and street children would require special attention. For example, a 10 - to 14-year-old non-school going boy said, ‘Medicines should be given to make them quit. Medicine is available. For example, it should be added to the food.’ In addition, community leaders indicated the need for collaboration between multiple community-based stakeholders and groups, de-addiction centres in communities and targeted interventions specifically for homeless and street children.
Enforcing tobacco control policies
The majority of participants (youth and adults) agreed that tobacco control laws were in place, but much needs to be done to strictly enforce the rules and fines. A 10 - to 14-year-old non-school going girl said, ‘They [community leaders] can impose a fine on the person who smokes.’
Emphasis was placed on the need to strengthen enforcement of tobacco control laws with stricter enforcement officials such as police and no tobacco advertising in any media. Law enforcement officials were identified as role models. In some cases, it was recommended using force and punishment to stop young people from using tobacco. A 10 - to 14-year-old non-school going boy said, ‘Tie his hands with a rope and keep him standing for half an hour. Like this! When he says sorry, then release him. No, tie him and don’t give him food. He should be given punishment.’
Additional suggestions by the participants
Suggestions were given to establish community tobacco cessation centres that could help youth to stop using tobacco and prevent uptake. An adult male said, ‘I have seen one hospital that is working for stopping tobacco use. Hospitals and NGOs can do work for stopping tobacco use.’
Community leaders also recommended that government should provide alternative forms of employment to tobacco dealers and also to non-school going children and take measures for poverty relief as part of tobacco control efforts. Some participants including youth and adults suggested measures such as closing tobacco shops, factories and local bidi production to curb production and marketing of tobacco products.
Discussion
Findings suggest that although youth and even adults in low SES communities in Delhi were generally aware of the harmful effects of tobacco use, they lacked information about the specific short-term and long-term health effects. These findings are in line with other studies among low SES youth in India [27]. Enhanced knowledge is protective against tobacco use [28], and the FGD findings highlight the need to reinforce information on the harmful ingredients in tobacco and on their specific impact on health in the short- and long term. Interestingly, youth (as well as community members) clearly associated tobacco use with wastage of household resources and diversion of income from other necessities such as tuition fees for school. Recent studies among low SES youth in India have suggested that on an average, youth spend less than INR 50 to INR 200 (US$1 to US $4.25) per day on tobacco products [29], whereas the average monthly family income is US$96 [30]. Hence, continued tobacco use in this group would further impoverish them and this would act as a hurdle to achievement of the millennium development goal to eliminate extreme poverty and hunger by 2015.
As reported elsewhere [31], young boys and girls in this study reported using tobacco products to impress the opposite sex. Similar to other studies from India and other countries [29, 32, 33], peer pressure was found to be the most common psychosocial determinant for the initiation and continuation of tobacco use. Consistent with previous reports from India [17, 28, 32], the youth reported lack of skills to refuse offers of tobacco from peers. Consistent, additionally, the influence of parents and family members leading to youth tobacco use was highlighted.
Youth and adult participants alike expressed serious concerns about the poor enforcement of tobacco control policies such as the ban on sales to minors and smoking in public places. Access to tobacco products was reported to be easy, consistent with reports of ineffective enforcement of the Indian Tobacco Control Law and findings that 84% of youth can freely purchase tobacco products from shops and street vendors [27, 29]. Some of the community leaders suggested that government should provide alternate employment to tobacco dealers or closing tobacco shops. This has been suggested as a tobacco control strategy in WHO Framework Convention on Tobacco Control [34], and support for the same was also demonstrated in the community through discussions. Advocacy and work on community attitudes could be important strategies to progress these changes. As part of Project ACTIVITY, an advocacy campaign in the communities was designed to address the enforcement of two provision of the Tobacco Control Law: prohibition of sale to minors and prohibition of smoking in public. Youth leaders engaged tobacco retailers in their respective communities and identified their familiarity with the Tobacco Control Law and barriers to adhering to its provisions; they also, with the help of adult community members, identified and created tobacco-free zones in their communities.
Most participants were aware of the addictive nature of tobacco use, but were not really aware of the harmful effects in the short- and long term, and thus a majority expressed scepticism about making a successful attempt to quit. This finding highlights a major barrier to reducing tobacco use in these communities. Youth and adults have to first understand the short- and long-term benefits of cessation, and then, it is possible to quit tobacco use with support from family, friends and health professionals.
Previous youth drug use intervention studies have shown that utilization of peer action and peer support networks can have long-term effects on reducing substance use, extending even into adulthood [33, 35–37]. Peer groups can have an influence on both promotion and reduction of tobacco use [38]. Given the important influence of peer pressure on tobacco use in our study population, Project ACTIVITY trained and supported peer leaders by building their skills and competencies to support and exhibit protective norms with regard to tobacco use.
The importance of engaging with elders—both in families and in communities at large, to build positive role models for the young people will be critical in this intervention. Several participants expressed frustration that parents, community leaders and even health professionals were sometimes negative role-models with respect to tobacco use.
However, this is unlikely to be effective, unless parents are first seen as setting tobacco and smoke-free norms in their homes and communities.
Based on our findings, parental practice of healthy behaviours is likely to have protective influence on the youth population vis-a-vis tobacco use. Given the general social norms in India, where young people typically refrain from using substances such as tobacco and alcohol in the presence of elders, tobacco-free parental behaviour will be critical to ensure that young children do not attempt to mimic parental risky health behaviour, albeit hidden from the public eye. Similarly, positive role models were provided by such community groups as health professionals, community leaders and religious preachers would be important.
A community-based intervention approach for all components of Project ACTIVITY has been helpful in engaging with families and other community stakeholders in youth tobacco use. Findings from this study indicate that it will be important to increase individual knowledge and self-efficacy in order to reduce and/or quit tobacco use, while simultaneously creating supportive environments through good role models and stronger policy enforcement. A community-based setting and the organization of tobacco cessation camps (a temporary settlement in communities to offer tobacco-related health screening and to support tobacco users to quit) may be the most appropriate way to provide cessation support. Tobacco cessation camps can be an effective way of reaching a large number of people to provide information and services regarding quitting tobacco use [39, 40, 41]. Multiple community stakeholders have been engaged in Project ACTIVITY including local leaders, civil society groups, religious leaders and health professionals. Doctors are well respected by people in these communities and it is important to involve them in intervention activities such as cessation camps. Sensitization of the community members with regard to existing tobacco control policies has created an enabling environment for better enforcement of legislation at the local levels.
Conclusion
The results of FGDs showed that the factors associated with tobacco use and cessation among youth in low SES communities in India are consistent with our conceptual model and can be rightly categorized into socioenvironmental and intra-personal factors. This study has informed the development of a tobacco prevention and cessation intervention for youth and suggests that the group needs focused attention. The study also provides a better understanding of the ‘social context’ of tobacco use, especially among disadvantaged and marginalized youth in Delhi, India. The need to sensitize children and youth about harmful health effects of tobacco use has been made quite evident. An early intervention may prevent experimenting with tobacco products.
Funding
Fogarty International Centre, National Institutes of Health (NIH), USA (R01TW007933).
Conflict of interest statement
None declared.
Acknowledgements
We thank the NGOs Centre for Applied Research and Education on Neuro-developmental Impairments and Disability-related Health Initiatives, New Delhi (CARENIDHI), and PRAYAS Institute of Juvenile Justice, New Delhi, for their contribution in recruiting the participants. We are also thankful to all the participants in this study without whose contribution this study would not have been possible. We are also thankful to Ms Aditi Bam from Public Health Foundation of India for copy editing this article.
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