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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 7
| Issue : 3 | Page : 109-114 |
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An observational study of compliance with tobacco-free school guidelines in Udupi district, Karnataka (India)
Gaurang P Nazar1, Shalini Bassi1, Nishigandha Joshi2, Muralidhar M Kulkarni3, Veena G Kamath3, Rohith Bhagawath3, John Britton4, Monika Arora1
1 HRIDAY, New Delhi; Health Promotion Division, Public Health Foundation of India, Gurugram, Haryana, India
2 HRIDAY, New Delhi, India
3 Department of Community Medicine, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 UK Centre for Tobacco and Alcohol Studies, University of Nottingham, Nottingham, United Kingdom
| Date of Submission | 20-Mar-2022 |
| Date of Decision | 23-May-2022 |
| Date of Acceptance | 21-Jul-2022 |
| Date of Web Publication | 15-Oct-2022 |
Correspondence Address:
Ms. Shalini Bassi
Health Promotion Division, Public Health Foundation of India, Plot No. 47, Sector 44, Gurgaon - 122 002, Haryana
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jncd.jncd_21_22
Background: National tobacco-free school guidelines were introduced in India in 2009. We assessed compliance with these guidelines across both government, government-aided, and private schools in Udupi district of Karnataka state in India.
Methods: We visited 915 upper primary and high schools across Udupi district and used a standardized checklist for visual inspection of the school environment and interviews with a school representative to ascertain compliance with guidelines (display of a tobacco-free school/institution board, presence of no smoking signage, no tobacco sale within 100 yards, presence of a Tobacco Control Committee, integration of tobacco control activities into the school health program, and availability of a copy of Cigarettes and Other Tobacco Products Act).
Results: A tobacco-free school board was displayed at the main entrance of 73% of schools, and there was no evidence of tobacco products on sale within 100 yards of 96% of schools. However, only 5% of the schools reported having the Committee; 4% reported having a copy of the Cigarettes and Other Tobacco Products Act, 2003 with the school, and no smoking signage was observed in < 1%. Integration of tobacco control activities into the school health program was reported in 91% of schools.
Conclusions: Compliance with tobacco-free school guidelines in Udupi was far from complete, indicating the need for enhanced implementation and monitoring.
Keywords: Compliance, India, observation, schools, tobacco
How to cite this article:
Nazar GP, Bassi S, Joshi N, Kulkarni MM, Kamath VG, Bhagawath R, Britton J, Arora M. An observational study of compliance with tobacco-free school guidelines in Udupi district, Karnataka (India). Int J Non-Commun Dis 2022;7:109-14 |
How to cite this URL:
Nazar GP, Bassi S, Joshi N, Kulkarni MM, Kamath VG, Bhagawath R, Britton J, Arora M. An observational study of compliance with tobacco-free school guidelines in Udupi district, Karnataka (India). Int J Non-Commun Dis [serial online] 2022 [cited 2023 Mar 26];7:109-14. Available from: https://www.ijncd.org/text.asp?2022/7/3/109/358628 |
| Introduction | |  |
Tobacco use is a major threat to developing countries such as India, which records close to a million tobacco-attributable deaths annually.[1] Nearly 28% of annual deaths due to chronic respiratory diseases and 15% of annual deaths due to tuberculosis in India are attributable to tobacco use.[2] The prevalence of tobacco use among adults in India has declined from 34.6% to 28.6% between 2010[3] and 2017,[4] and among Indian adolescents (aged 13–15 years) from 16.9% (2003) to 8.5% (2019).[5] As the majority of adult tobacco users initiate its use in adolescence,[6] prevention of tobacco uptake among children and adolescents is of utmost importance for effective tobacco control.
The Government of India (GoI) introduced the Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act (COTPA) in 2003, with preventing uptake of tobacco use by children and adolescents as one of its objectives.[7] Section 6a of COTPA stipulates prohibition on the sale of tobacco products to and by minors, and Section 6b mandates prohibition on the sale of tobacco products around 100 yards of educational institutions.[7] In order to ensure effective implementation of these provisions and to provide a momentum to tobacco control initiatives in adolescents and young people, the Ministry of Health and Family Welfare (MoHFW), GoI, introduced tobacco-free school guidelines.[8] These guidelines include the formation of “tobacco-free youth clubs” in schools, mandatory display of boards stating: “tobacco-free institution” or “tobacco-free school” and “prohibition of sale of cigarettes or any other tobacco products in an area within a radius of 100 yards of the school” on the boundary wall outside the main entrance of school, and the placement of “No Smoking – Smoking here is an offence” signage at conspicuous places inside the school. Among other mandatory requirements, guidelines specify the constitution of an empowered “Tobacco Control Committee” in each school, consisting of members including teachers, students and youth, parents, area Member of the Legislative Assembly, and other stakeholders.[8]
Despite the existence of tobacco-free school guidelines in India, little research[9],[10],[11],[12] has been conducted to comprehensively access the extent to which these are implemented. These studies were undertaken in a specific region of the country and observed a low compliance with the COTPA provisions specific to ban on sale of tobacco products to and by the minors, and around educational institutions. We studied the implementation and compliance with tobacco-free school guidelines in Udupi district of Karnataka (India), a reportedly high COTPA compliance district.[13] The study was conducted in both rural and urban areas of Udupi district among government, government-aided, and private schools.
| Methods | | |
Study design and setting
This cross-sectional study was conducted in all upper primary and high schools in urban and rural areas of five educational blocks (Brahmavara, Byndoor, Karkala, Kundapura, and Udupi) of Udupi district, a coastal region of Karnataka state in South India. The list of total schools in the district was procured from the office of the Deputy Director of Public Instructions. Of the total 1214 schools in Udupi district listed by the education department, we excluded 295 schools: schools that had closed (n = 5), special schools for differently abled children (n = 7), lower primary (n = 281) and high schools with no students in grades 6–8 (n = 2). The principals of the remaining 919 schools were contacted by the trained research staff and schools that provided their consent to participate (n = 914, 99.4%) were included in the study. Schools were recruited from May to November 2017, and data were collected by research staff between August 2017 and January 2018. Data collection involved direct observation of the school environment and an interview with a school representative, usually the Principal.
Measures
A standardized checklist for data collection including questions and measures from the tobacco-free school guidelines[8] endorsed by the Central Board for Secondary Education[14] and the state government of Karnataka was used.[15] The checklist was developed in English and translated into Kannada language, and included 11 items dedicated to the observation of the school's physical environment, and 12 items dedicated to a one-on-one interview with the school representative [Supplement Table 1] and [Supplement Table 2]. Key indicators for compliance with tobacco-free school guidelines[8],[14],[15] were as follows:
- Observed display of a board restricting the sale of tobacco products within a radius of 100 yards (approximately 90 m) from the educational institution
- Observed display of “No Smoking Area – Smoking Here is an Offence” signage inside the school at conspicuous places
- Reported sale of any tobacco products within a radius of 100 yards (approximately 90 m) from the school
- Reported presence of a Tobacco Control Committee in schools
- Reported integration of tobacco control activities with the school health program or health and wellness clubs
- Observed availability of a copy of COTPA (2003) in schools.
Other indicators included observed free distribution of any tobacco products or tobacco-related materials or presence of tobacco-related advertisements or promotions around any of the schools; use of tobacco products in schools by students, teachers, other school staff, or visitors (reported and observed); observed presence of used bidi/cigarette butts or used tobacco sachets in the schools; any reported tobacco control/awareness activities conducted in the schools; and any certificates of appreciation reportedly presented for contribution by students, teachers, or other school staff to tobacco control activities.
Data collection
The heads of the schools were contacted telephonically by the research staff, and an appointment was sought to visit them personally to explain about the study. After taking an appointment, the research staff visited each selected school to request informed consent for participation from the school principal at a date and time convenient to the school. In each school, observation of the school's physical environment was carried out first and followed by a one-on-one interview with the school representative. The school representative was usually the Head Teacher, but if not present on the day of visit, then teacher in-charge was interviewed. The duration of each school visit was typically 30–40 min.
Data analysis
Data were entered in Microsoft Excel 2016 and cross-checked for errors. We report overall descriptive statistics (frequencies and percentages) for the indicators described above. To compare differences in compliance between school types (government/government aided and private) and location of the school (rural/urban), we present descriptive statistics for these subgroups. We used the Pearson's Chi-square test or the Fisher's exact test, as appropriate, to study univariate associations between the subgroups and the compliance indicators. Differences were considered significant at the significance level of 0.05. Data analysis was conducted using STATA v. 13.1 (StataCorp LP, Texas, USA).
| Results | | |
Of the 924 potentially eligible schools in Udupi district, 5 had permanently closed and 4 declined to participate. Thus, 915 schools were included, of which 52% (n = 476) were government schools, 27% (n = 251) government aided, and 21% (n = 188) private schools. The majority (85%) of schools were in rural settings (n = 776).
Boards restricting the sale of tobacco products within a radius of 100 yards of the educational institution were present on the outer boundary wall near the main gate of 73.1% (72.4% of rural and 77% urban) schools. The boards were more prevalent among (78%) government and government-aided schools than private schools (54.3%) (P < 0.001) [Table 1]. | Table 1: Compliance with key tobacco-free school guideline indicators (n=915 schools)
Click here to view |
The display boards “No smoking area – Smoking here is an offence” were not observed in the majority of schools studied (99.8%), being present in only two government/aided schools [Table 1].
Sale of tobacco products was not observed within a radius of 100 yards for the majority of schools (96.4%), though this figure was higher for private schools (98.9%) than government and government-aided schools (95.7%) (P = 0.045) [Table 1]. There were no significant differences in this indicator by the location of the school [Table 1].
Of all the schools studied, only 4.6% reported having constituted a Tobacco Control Committee [Table 1]. This proportion was higher in private schools (10.1%) than in government and government-aided schools (3.2%) (P < 0.001) [Table 1]. Similarly, 8.6% of schools in urban areas reported having constituted the Committee compared with 3.9% of schools in rural areas (P = 0.013) [Table 1].
Representatives from 91.4% of schools reported that tobacco control activities were integrated with their school health program or as part of their health and wellness clubs [Table 1]. 92.9% of government and government-aided schools and 85.6% of private schools reported integrating such activities (P = 0.002) [Table 1].
A hard copy of COTPA (2003) was available with the school administration in only 3.8% of schools studied [Table 1]. Again, there were significant differences in 6.9% of the private schools, compared with 3% of government and government-aided schools reported having a copy of COTPA (2003) (P = 0.013) [Table 1]. There were no significant differences between schools in urban and rural areas for this indicator [Table 1].
We found similar results in a repeat survey carried out in 2018, except for the integration of tobacco control activities with school health program or health and wellness clubs which had dropped significantly from year one.
Other key findings (data not shown)
There was no observed free distribution of any tobacco products or tobacco-related materials or the presence of tobacco-related advertisements or promotions around any of the schools studied. Although students, teachers, or other school staff were not observed or reported to be using tobacco products in any of the schools studied, visitors were observed doing so at eight government/aided schools in rural areas. In 19 government/private/aided schools, the use of tobacco products on premises was reported by the school representatives. Used bidi/cigarette butts or used tobacco sachets were found in 4% of schools studied (mostly in government/aided schools from rural areas). Although the sale of tobacco within 100 yards of school radius was observed around 33 schools by our staff, school representatives of 13 additional schools reported that neighborhood shops continued selling tobacco but would give tobacco only on demand and, to those who they know, use tobacco. School principals/school heads were asked if they provided any certificates of appreciation to their staff (teachers) and students for conducting any tobacco control activities in school, almost none of the schools had provided any certificate to appreciate the efforts of staff and students.
| Discussion | | |
This study demonstrates compliance with some tobacco-free school guidelines, particularly the sale of tobacco products within a radius of 100 yards from schools and integration of tobacco control activities in school health programs. However, despite the fact that Udupi district has been proclaimed as a highly COTPA compliant district,[13] relatively low compliance was observed for other guideline components, including (particularly among private schools) display of tobacco-free school or tobacco-free institution boards at the main entrance of the school, and particularly for display of no smoking signage at conspicuous places inside the school. Consistent noncompliance was reported with respect to the availability of hard copy of COTPA (2003) across all types of schools in all locations. Compliance with the requirement for a Tobacco Control Committee in schools was consistently poor across school types and location of schools, and is likely to inhibit reporting of violations of tobacco-free school guidelines. Although students, teachers, and other staff from most of the schools in Udupi district did not seem to use tobacco products inside the schools, some schools from rural areas reported violations with regard to the use of tobacco products by visitors inside schools.
Our findings are consistent with those of the few other studies that have assessed compliance with tobacco-free school guidelines in India. A study of 30 randomly selected schools in Mangaluru (Karnataka) in 2017 reported that only 10% of schools complied with the requirement of no smoking signage and availability of a copy of COTPA (2003) with the school administration, while frequent violations related to sale of tobacco products around 100 yards radius were observed.[11] Similarly, poor compliance with tobacco-free educational institution guidelines was reported in a study conducted with 1408 educational institutions across four districts in India in 2013;[10] another study conducted with 507 schools in rural settings of Maharashtra in 2017[9] and a cross-sectional study conducted in 2019 among 84 schools in Haryana found that none of the schools thoroughly complied with the tobacco-free school policy.[12] A major difference in our study was compliance with restrictions on the sale of tobacco products around schools; this may indicate effective implementation of this measure by the enforcement agencies.
Strengths and limitations of the study
The strength of our study lies in the fact that this study was conducted with a large and highly representative sample of schools. Data were collected from both government/government-aided and private schools in both rural and urban parts of a district of Karnataka which is reportedly highly COTPA compliant.[13] Our findings are, therefore, likely to indicate the best possible scenario in the country in terms of compliance with tobacco-free school guidelines. Our study was limited in scope (observational study) in that we did not collect detailed information which could enable us identify factors responsible for noncompliance with the tobacco-free school guidelines. Findings from this study necessitate further research into this. Further, the limited scope of the study did not allow us to plan any intervention to address noncompliance with guidelines except for presenting the findings to health and education departments of the state. Some of the outcomes of this study (reported sale of tobacco products in a radius of 100 yards around the schools, presence of a Tobacco Control Committee in schools, and integration of tobacco control activities in school health program or health and wellness program) were self-reported and likely to suffer from response bias, but findings were reported in most cases by the school Principal and hence assumed to reflect the actual situation.
| Conclusions | | |
The MoHFW, GoI, did a commendable job of introducing the tobacco-free educational institution guidelines.[16] The guidelines demonstrate the commitment of the government to protect minors from tobacco and create anti-tobacco social norms. Except for sale of tobacco in a radius of 100 yards around educational institutions, our study shows poor compliance with other provisions of the guidelines irrespective of school type or setting of the school. This indicates a lack of monitoring and highlights wider implementation challenges in tobacco control in India, consistent with findings reported in earlier studies.[17],[18],[19] Our study, in consonance with some of the earlier studies, should act as a catalyst to fuel remedial measures aimed at strengthening the implementation of tobacco control measures at the national, state, and district levels. In the global context, our findings underscore the urgent and unmet need for the adoption of evidence-based guidelines on the implementation of the WHO Framework Convention on Tobacco Control Article 16, which would be invaluable for protecting minors from tobacco.
Acknowledgment
The authors would like to acknowledge the contributions of Ms. Manjusha Chatterjee (Consultant PHFI, Gurugram), who contributed toward developing the study proposal and the checklist for data collection, and Dr. Surbhi Tripathi (JIPMER, Puducherry), who assisted with data analysis.
Ethical approval statement
Permission for the study was obtained from the Deputy Director of Public Instructions (Udupi district), Health Ministry's Screening Committee (Ref. No. 2017-0460), and ethics approvals from the Institutional Ethics Committee at the Centre for Chronic Disease Control, New Delhi (CCDC_IEC_11_2018), Manipal Academy of Higher Education (EC/012/2017), and the Research Ethics Committee at the University of Nottingham (OVS200317).
Financial support and sponsorship
This research work is funded by the Medical Research Council of the United Kingdom under the Global Alliance for Chronic Lung diseases Program (MR/P008933/1) and was carried out as part of a collaborative project of the University of Nottingham, Manipal Academy of Higher Education, HRIDAY, and the University of Bath.
Conflicts of interest
There are no conflicts of interest.
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