Beyond the puff: unravelling patterns and predictors of tobacco usage among adolescents and youth in Delhi, India

Introduction

Tobacco use, with a primary emphasis on cigarette smoking, stands as a significant and pervasive public health challenge with dire global implications. The toll exacted by tobacco is staggering, with over eight million lives claimed annually worldwide [1]. Of this grim statistic, seven million fatalities are directly attributed to tobacco use, while an additional 1.2 million result from exposure to second-hand smoke [2]. The ubiquity of cigarette smoking makes it the most prevalent form of tobacco consumption on a global scale, although other products such as water pipe tobacco, various smokeless tobacco items, cigars, cigarillos, rolling tobacco, and bidis also play roles in the wider landscape of tobacco usage [3]. Alarmingly, data gleaned from previous studies underscores that nearly 90 % of adult smokers embark on their tobacco journey before the age of 18 [4]. In 2015, the prevalence of current tobacco users, encompassing all forms of tobacco, constituted 24.9 % of the global population. Within this context, the prevalence of tobacco use among youth aged 1524 in 2015 was estimated at 17 %, with notable disparities between genders, where 27.6 % of males and 5.6 % of females were identified as users [5].

Zooming in on India, insights from the GATS-2 survey reveal that the overall prevalence of any form of tobacco usage among youth stands at 11.9 % [6]. More granularly, the prevalence of current smoking and smokeless tobacco use is identified at 5 % and 10.9 %, respectively [6]. Delving deeper into the behavioral aspects, the mean age of initiation for tobacco use in the Indian context is found to be 20.9 years, with the average age of commencing daily smoking at 17 years and the initiation of smokeless tobacco usage at 22.3 years [7]. The repercussions of tobacco use are far-reaching and manifold, encompassing a heightened risk of various ailments, including cancers, heart disease, stroke, lung diseases, diabetes, and chronic obstructive pulmonary disease (COPD), which comprises conditions such as emphysema and chronic bronchitis. Furthermore, tobacco usage elevates susceptibility to tuberculosis, certain ocular diseases, and immune system disorders, such as rheumatoid arthritis [8].

Tobacco use among adolescents and youth in India has emerged as a critical and multifaceted public health concern. The juxtaposition of the world’s largest youth population with a persistent prevalence of tobacco consumption presents a complex challenge with significant implications for both current and future generations. This issue not only threatens the health and well-being of Indian adolescents and youth but also poses long-term socio-economic consequences. India’s demographic landscape is characterized by a burgeoning youth segment, with a substantial percentage falling within the age bracket of 15–24 years. This age group is particularly vulnerable to the allure of tobacco, with the potential for lifelong addiction and the associated health risks. Understanding the dynamics of tobacco use among Indian youth is crucial, as it sets the stage for effective interventions, policy development, and public health initiatives.

Hence the current study was undertaken to delve into the prevailing patterns, prevalence rates, and socio-cultural factors illuminating the complex tapestry of tobacco use among college students and youth in Delhi, India. By shedding light on the nuanced interplay between tobacco and youth in India, we aim to provide a foundation for informed decision-making, preventive measures, and targeted interventions that can safeguard the health and future of this vital demographic.

Materials and methods

Sample size

This study forms part of a larger research project, and the sample size calculation was determined based on parameters established in a previously published study [9]. The final sample size calculated was 675.

Figure 1:

Flowchart for selection of study participants.

Results

The study was conducted among 675 undergraduate students from Delhi University, with a mean age of 19.62 years (SD= ± 1.328). Participants were aged between 17 and 23 years, with 48.9 % in the 17–19 age group and 51.1 % in the 20–23 group. Of the participants, 52.6 % were female and 47.4 % male. Most identified as Hindu (84.4 %), followed by Muslim (8.7 %) and Christian (2.7 %). A majority (74.8 %) were from urban areas, and 63.3 % of mothers had at least a graduate degree. Regarding fathers, 65.5 % had a graduate or postgraduate education. Socio-economic status showed 71 % of participants from the upper class, 17.4 % from the upper middle class, and 7.1 % from the middle class. Most students were pursuing Arts (34.5 %), followed by science (33.8 %) and Commerce (31.7 %). Academically, 75.1 % had grades above 70 %. In terms of future plans, 45.9 % intended to continue their studies, 22.8 % aimed to work, and 22.4 % planned to both work and study.

Regarding parental employment, 72.4 % of participants had fathers working, 24.8 % had both parents working, and 1.6 % reported that only their mothers were employed. 75.7 % of participants lived with their parents, while 24.3 % lived away, including 12.5 % in hostels. BMI analysis showed 14.3 % underweight, 49.6 % normal weight, and 36 % overweight or obese. Among underweight participants, 76 % were female, while 55.2 % of overweight participants were male. 56.9 % of obese participants were male (Table 1).

Discussion

The present study was conducted among 675 undergraduate students from five selected colleges to assess the prevalence of tobacco use and the factors associated with it. The study found that 38.9 % of participants had ever used any form of tobacco, with 23.7 % participants reporting current use. These findings are similar to those of Malhotra et al. [11], who reported 34 % for ever tobacco use and 25 % for current use. Among the specific types of tobacco use, 31.3 % of students had ever smoked, and 20.3 % were current smokers. The prevalence of ever hookah use was 27 %, while 14.7 % of students had ever used e-cigarettes. Smokeless tobacco use was relatively low, with 5.3 % reporting ever use and 2.2 % using it currently. Comparisons with other studies revealed both higher and lower prevalence rates. For example, Anand et al. [12] reported a lower rate of 22.9 % for ever tobacco use among female students at Delhi University, while studies by Nagendra et al., Kumar et al., and Mohanan et al. reported much lower prevalence rates (7.4 %, 16.4 %, and 7.2 %, respectively) [13], [14], [15]. In contrast, smokeless tobacco use was higher in studies by Sharma et al. and Malhotra et al., which reported 11 % and 8.2 %, respectively [11], 16]. However, prevalence rates similar to the current study were found in a study by Jodalli et al., which reported 4.8 % for smokeless tobacco use [17]. The variation in prevalence across these studies can be attributed to differences in study settings, populations, and time periods.

In the present study, no significant difference was observed between current tobacco use and gender (p>0.05). This finding contrasts with previous studies by Jodalli et al. (Mangalore, Karnataka, 2020), Janeswar et al. (Bhubaneswar, Odisha, 2019), Kumar et al. (Delhi, 2014), Mohanan et al. (Udupi, Karnataka, 2014), Mukhopadhyay et al. (West Bengal, 2012), and Sharma et al. (Delhi, 2010), all of which reported gender-based differences in tobacco use [14], 15], [17], [18], [19], [20]. In the current study, a higher percentage of males (58.1 %) were current tobacco users compared to females (41.9 %). However, after controlling for other factors, the association between gender and tobacco use was found to be non-significant. This discrepancy could be attributed to differences in the operational definition of tobacco use. In the present study, tobacco use was defined as the consumption of any form of tobacco, including cigarettes, smokeless tobacco, hookah, or e-cigarettes, whereas many previous studies have focused solely on smoking or smokeless tobacco.

Interestingly, the current study also suggests a shift in trends, with an increasing number of females using tobacco compared to earlier years. In addition, the study found a significant association between current tobacco use and the father’s educational status. Students whose fathers had attained at least a graduate-level education were 0.4 times less likely to be current tobacco users compared to their peers (p<0.05). This aligns with the notion that higher parental education may play a protective role in preventing tobacco use among youth.

The study further revealed a significant association between academic performance and current tobacco use, with students performing poorly academically being six times more likely to use tobacco compared to their high-performing counterparts. This finding is consistent with previous research by Mukhopadhyay et al. (West Bengal, 2012) and Jones et al. (USA, 2020), who also found low academic achievement to be associated with higher tobacco use [19], 21].

Additionally, students’ living arrangements were significantly related to tobacco use. Those living away from their parents (in hostels, with friends, or alone) were three times more likely to use tobacco compared to those living with their parents. This is in line with findings from Peltzer et al., who also observed higher tobacco use among students living independently [22].

Psychological distress was another factor significantly associated with current tobacco use. Students experiencing high levels of psychological distress were 1.9 times more likely to use tobacco than those with low or no psychological distress (p<0.05). This finding is supported by previous studies, such as those by Jones et al., Peltzer et al., and Grant et al., who also noted a positive correlation between psychological distress and tobacco use [21], [22], [23].

Substance abuse was similarly found to be a strong predictor of tobacco use, with individuals who had ever used any substance being 5.6 times more likely to use tobacco currently compared to those who had never used substances (p<0.05). This is consistent with studies by Grant et al. and Peltzer et al., which also highlighted the link between substance use and tobacco consumption [22], 23].

However, no significant associations were found between age, socioeconomic status (SES), study subject, year of study, or place of origin (rural/urban) and current tobacco use. These results align with studies by Sharma et al., who found no relationship between SES and tobacco use, and Jodalli et al., who reported no significant associations between age or rural-urban location and tobacco use [16], 17]. In contrast, Kumar et al. observed a significant rural-urban difference in tobacco use, indicating that regional factors may also play a role in tobacco consumption patterns [24].

In summary, the current study provides insights into the complex factors influencing tobacco use among students, highlighting the significance of family education, academic performance, living arrangements, psychological distress, and substance abuse as key predictors, while gender, age, and SES appeared to have a lesser impact.

The study’s strengths include the use of a pre-designed, pre-tested, and validated tool for data collection, enhancing the reliability of the results. It was conducted across five different administrative zones in Delhi, ensuring a representative sample of participants. Additionally, a scientific methodology was employed for sample size calculation and participant selection, and identifiers were removed to maintain anonymity and reduce social-desirability bias. However, the study also has limitations. Its cross-sectional design prevents establishing causality. Conducted among students from a single university in Delhi, the findings may not be generalizable to other universities or the broader population in India. Additionally, as the study was based in an urban setting, the results may not reflect the experiences of students in non-urban areas. The self-report nature of the survey may also introduce under-reporting or over-reporting biases.

Despite its limitations, the findings from this study are promising and contribute valuable insights to the existing body of evidence on tobacco use patterns among this vulnerable population. These findings can help inform policymakers in addressing this growing issue in society.

Conclusions

In conclusion, this study highlights a relatively high prevalence of tobacco use among college students, particularly in urban areas, emphasizing the need for targeted interventions. Cigarettes ranked as the top choice of tobacco product among the study population, underlining the urgency for health professionals, educators, and policymakers to implement specific strategies aimed at preventing tobacco use among youth. Despite existing regulations governing the sale of tobacco and alcohol, underage individuals continue to access these substances, calling for a re-evaluation and stricter enforcement of laws. Additionally, monitoring systems should be established to prevent violations, with harsher penalties for those selling to minors. The current health system, which focuses predominantly on curative care, must shift towards a greater emphasis on health promotion and disease prevention. This shift is especially crucial for youth, where preventive measures can be more effective than treatment. Comprehensive, evidence-based educational and promotional programs targeting multiple health risk behaviors are essential for deterring young people from engaging in risky behaviors. These programs should be developed based on scientific evidence and tailored to the specific needs of college students, incorporating their input for greater relevance and success. Furthermore, involvement of teachers and parents, alongside the sensitization of the wider community, is vital in addressing tobacco use in this population. Parents significantly influence adolescents’ choices and decisions, serving as vital role models. Understanding their impact is essential and future studies can study this aspect. Longitudinal studies across universities and colleges are needed to better understand trends and refine intervention strategies.