Open Access

Prevalence and correlates of tobacco use among adolescents in the schools of Kalaiya, Nepal: a cross-sectional questionnaire based study

  • Ravi Kumar Bhaskar1Email author,
  • Mukti Narayan Sah2,
  • Kumar Gaurav1,
  • Subhadra Chaudhary Bhaskar3,
  • Rakesh Singh1,
  • Manoj Kumar Yadav1 and
  • Shatrughna Ojha1
Tobacco Induced Diseases201614:11

https://doi.org/10.1186/s12971-016-0075-x

Received: 3 September 2015

Accepted: 22 March 2016

Published: 31 March 2016

Abstract

Background

Adolescent students are vulnerable group for tobacco addiction. Tobacco use among school children is becoming a serious problem in developing countries. This study was carried out to estimate the prevalence of tobacco use and to determine associated factors among adolescent students of Kalaiya municipality.

Methods

A cross sectional survey was carried out by self-administered questionnaire adapted from Global Youth Tobacco Survey to assess tobacco use among the representative sample of 1540 adolescent students selected by stratified random sampling from December 2014 to May 2015.

Result

Overall prevalence of ‘ever users’ of tobacco products was 25.3 %. Prevalence among boys and girls was 31 and 14.4 % respectively. Mean age at initiation of using tobacco was 13.38 ± 1.62 years. The correlates of tobacco use were: sex, ethnicity, family members and friends using tobacco products, and students exposed at home and public place.

Conclusion

School based interventions and tobacco education are necessary to prevent initiation and cessation of tobacco use. Legislations related to tobacco control should be enforced to decrease availability, accessibility and affordability of tobacco products. Social norms of tobacco use among parents and others at home as well as at public place should be modified to curb the tobacco use among school students.

Keywords

Adolescents Determinants Smoking Prevalence Tobacco use GYTS Correlates

Background

Tobacco use is a risk factor for six of the eight leading causes of deaths in the world. The six causes are cancers of respiratory tract, ischaemic heart disease, cerebro-vascular disease, chronic obstructive pulmonary disease, tuberculosis and lower respiratory tract infections [1]. Smoking tobacco causes cancer of the lung, larynx, kidney, bladder, stomach, colon, oral cavity and esophagus. It also causes leukaemia, chronic bronchitis, chronic obstructive pulmonary disease, ischaemic heart disease, stroke, miscarriage and premature birth, birth defects and infertility among other diseases [2]. Tobacco use (smoked as well as non-smoked) was also found to be associated with migraine [3].

Tobacco use is the leading global cause of preventable death. Currently about 5 million deaths per year are attributable to tobacco which is expected to rise to more than 8 million deaths a year by 2030. There is estimation that three quarters of these deaths will be in low and middle income countries [2]. Most people begin using tobacco in their adolescent age [4]. Adolescents are the persons in the 10–19 years age group [5]. The use of tobacco among the adolescent and youth, in smoking as well as smokeless forms, is quite high in the South East Asian Region [5]. Nepal is a low income land locked country in SEAR and has 26.6 million populations including 24.2 % adolescents [6].

Geographically Nepal is divided into three Regions: Himal, Pahad and Terai. Himal is the high mountainous area in the northern part of the country. Terai is situated in southern part and it is having plain low land area. Pahad is the hilly area situated in between Himal and Terai. Kalaiya is situated in central Terai region. It is the district headquarter town of Bara district, one out of seventy five districts in Nepal. It has tropical climate. Although majority of the population are Hindus, other religious group includes Muslims, Christians and Buddhists. Kalaiya has multi-ethnic population. There are total 20 schools including 5 government schools.

The Framework Convention on Tobacco control had been signed by Government of Nepal on 3 December 2003 and ratified by parliament on 7 November 2006 [7, 8]. Government had also enforced and implemented the Tobacco Product Control and Regulatory Act 2011, Tobacco Product Control and Regulatory Rule 2012 and Directive for Printing and Labeling of Warning Message and Picture in the Box, Packet, Wrapper, Carton, Parcel and Packaging of Tobacco Product, 2011 in country. This show strong will of government to control tobacco use [7, 8]. Apart from this, prevalence of tobacco use is high as well as it is increasing. Enforcement of tobacco control measures and their weak regulation should be properly implemented to address the problem.

Tobacco is used in a wide variety of ways in Terai (southern plain land of Nepal) including smoking and smokeless form. Tobacco is smoked in the forms of Beedis, cigarettes or by using devices like hooka, chillum [9]. Beedi is a cheap smoking stick, handmade by rolling a dried, rectangular piece of leaf of Diospyros melanaxylon with 0.15–0.25 g of sun-dried, flaked tobacco filled into a conical shape and the roll is secured with a thread. Hooka is an indigenous device, made out of wooden and metallic pipes, used for smoking tobacco. Chilam is conical pipe made of clay, used for smoking tobacco only or mix of Ganja (Marijuana) and tobacco [9]. Tobacco is used in a number of smokeless forms which include, Khaini/Surti, gutka, Zarda, snuff and as an ingredient of pan masala [9, 10]. Khaini/Surti consists of roasted tobacco flakes which are mixed with slaked lime by keeping on palm of a hand and rubbing it with thumb of another hand and used as a pinch kept in labial or buccal sulcus. Snuff is a black-brown powder obtained from tobacco through roasting and pulverization which is used via nasal insufflations. Gutka is a manufactured smokeless tobacco product (MSTP), a mixture of areca nut, tobacco and some condiments, marketed in different flavors in colorful pouches. Pan masala is a betel quid mixture, which contains areca nut and some condiments, but may or may not contain tobacco. The mixture is chewed and sucked [9].

A national Global Youth Tobacco Survey 2011 (GYTS) in Nepal reported that overall 10 % of the students ever smoked cigarettes and 20.4 % ever used tobacco in other forms [4]. Only 3.1 % students are current smokers while 19.1 % students are current other tobacco users. GYTS 2007 in Nepal revealed that overall 7.9 % of the students ever smoked cigarettes, 8 % used other tobacco product, 3.9 % were current smokers [5]. It reveals tremendous increase in current other tobacco users from 7.2 % in 2001, 8 % in 2007 to 19.1 % in 2011. The trend of use of tobacco is increasing among students [4].

Some of the factors known to be associated with tobacco use among adolescents are age, gender, having smoker friends or parents [5, 11]. Adolescents are vulnerable group for experimenting with tobacco and adopting the risky health behaviour [12]. There is more prevalence of tobacco use among male than among female adolescents [4, 5]. The adolescents having smoking friend or parents are more likely to have tobacco use [1216].

The present study was carried out with the objectives to estimate the prevalence of tobacco use and to determine the associated factors among adolescent students of Kalaiya municipality of Bara district of central Nepal.

Methods

Study design and setting

This was a school based cross-sectional study conducted in Kalaiya Municipality from December 2014 to May 2015. Kalaiya is situated 350 km from capital city, Kathmandu. It is headquarter city of Bara district, which is situated in central Terai region and is bordered in south with Bihar state of India.

Sample size, study population and sampling technique

The sample size was calculated using formula pq(Zα/e)2 at 95 % confidence limits and at allowable error 10 % of prevalence [17]. The prevalence of tobacco use was 20.4 % during GYTS 2011 [4]. The calculated sample size was 1499.

Students of grade 8, 9 and 10 from Kalaiya municipality were included in the study. List of schools in Kalaiya was obtained from District Education office. We targeted to distribute at least 100 questionnaires in one school. Out of 20 schools in the list, 4 schools were excluded as they have less than 100 students. Remaining 16 schools were selected and all schools agreed to participate in the study (School response rate = 100 %). To obtain 1499 complete questionnaire, 1649 high school students (assuming 90 % response rate) were targeted for sample selection by random sampling technique.

Data collection

Data were collected using a self-administered questionnaire adapted from GYTS. The questionnaire was translated into Nepali language and was pre-tested among the adolescent students in different school. Necessary corrections and modifications in the questionnaire were made to make it more comprehensible for the students. Before data collection, an elaborative briefing on the questionnaire was done to all the students of the class of all the selected schools.

A total of 1649 questionnaires were distributed to students in 16 schools and 1550 questionnaires were filled in and submitted to the investigator (student’s response rate = 91.23 %). Ten questionnaires were partly filled, thus they were excluded. Finally 1540 questionnaires were included in analysis.

Study variables

Tobacco ever use was considered as dependent variable while age, gender, ethnicity, type of school, tobacco use in family members, tobacco use among friends, knowledge about harmful effect, perception about use and exposure to tobacco smoke as explanatory variables.

Ever user was defined as one who had not used any form of tobacco (smoked or chewed) in the past 1 month but had tried in the past. Participants were assessed for ever use of tobacco by asking ‘Prior to the past 30 days, have you ever smoked or chewed tobacco?’ After an affirmative response to this question, Participants were asked about type of tobacco. The options were cigarette, beedi, pan masala, surti, khaini, gutka, snuff, Hookah and specify others, if any.

Current user was defined as one who had used any form of tobacco (smoked or chewed) in the past 1 month. Never user was defined as one who had not tried any form of tobacco. Ethnic groups were broadly classified into Brahmin/Chhetri, Janajati, Dalit and Madhesis as each ethnic group is a collection of many castes which have common customs, socioeconomic, cultural and traditional values. Respondents were asked about harmful effects of tobacco through an open question by asking “can you enumerate the harmful effect of tobacco use. The response was categorized into no knowledge (Reporting no health problems), some knowledge (reporting 1–3 relevant health problems) and good knowledge (Reporting 4 or more relevant health problems). Respondents were asked the responses either yes or no for Tobacco use in family members and tobacco use among their friends. After an affirmative response to this question, Participants were asked about type of tobacco consumed by their family member/friend.

Data analysis

Data checking, editing and coding was done by the researcher each day. Data entry was done in MS Windows Excel and analysis was done in SPSS 17. Data coding, recording and cleaning was continuously carried out to ensure data quality. Descriptive analysis was done and prevalence was estimated for 95 % confidence interval. Chi-square test was applied to test whether the explanatory variables were significantly associated (p value < 0.05) with tobacco use at 95 % confidence interval. Binary logistic regression analysis with backward elimination was used to determine the independence of associations observed in bivariate analysis by controlling for potential confounding factors. Crude and Adjusted Odds ratio (OR/AOR) with 95 % CI were also calculated to quantify the associated risk factors.

Ethical considerations

Ethical clearance was taken from Institutional Ethical Review Board of National Medical College at the start of the study. Written permission was obtained from selected school authorities. Informed consent was taken from the participants. All the students present at the time of the visit were explained about objectives of the study, were assured of full confidentiality of the responses and asked for their voluntary participation. Absence of any teacher or other personnel at the time of data collection was ensured to prevent response bias.

Result

Socio-demographic characteristics

Table 1 shows socio-demographic characteristics of the students. Median age of the respondents was 14.49 ± 2.97 years. Out of total respondents, 65.8 % were male and 34.2 % were female students. Respondents who were Madhesis by ethnicity were predominant. Majority of the respondents were Hindus. Participation was almost equal from government as well as non-governmental school (Ratio = 1:1.24).
Table 1

Socio-demographic characteristics of students of kalaiya municipality

Characteristics

Number

Percentage

Age (Years)

 10–12

14

0.9

 13–15

1012

65.7

 16–18

514

33.4

Grade

 Eight

408

26.5

 Nine

777

50.5

 Ten

355

23.1

Sex

 Male

1014

65.8

 Female

526

34.2

School

 Governmental

854

55.5

 Non-governmental

686

44.5

Religion

 Hindu

1299

84.4

 Muslim

213

13.8

 Othersa

28

1.8

Ethnicity

 Brahmin/chhetri

213

13.8

 Dalits

102

6.6

 Janjatib

205

13.3

 Madhesic

708

46.0

 Muslims

213

13.8

 Othersd

99

6.4

a other religion includes Christian, budhism, Jainism

b janjati includes tharu, mandal (dhanuk), magar, limbu

c Madhesi includes Kanu, kalwar, teli, kushwaha, yadav and other terai origin castes

d other ethnicity includes marwadi, Bengali, tamils

Some students reported initiation of tobacco use as early as 6 years and maximum age of initiation was 16 years. The mean age of initiation was 13.38 ± 1.62 years.

Prevalence of ever and current tobacco use

The prevalence of ever tobacco use was 25.3 % in our study. The prevalence of ever tobacco use among male and female students was 31 % and 14.4 % respectively. Among the total ever tobacco users (Prevalence = 25.3 %), 7.7 % had smoked (Cigarrette/Beedi), 9.2 % had used Surti/Khaini and 8.4 % had used Gutka/pan masala (Table 2).
Table 2

Prevalence of tobacco use among students

Charecteristics

Prevalence of ever use of tobacco in any form

Prevalence of ever use by type of tobacco

Never user of tobacco in any form

Cigarette/beedi

Surti/khaini

Gutka/Pan-masala

Total

25.3 %

7.7 %

9.2 %

8.4 %

74.7 %

Sex

Male

31 %

9.4 % (

10.1 %

10.7 %

69 %

Female

14.4 %

4.3 %

4.3 %

5.7 %

85.6 %

Type of school

Government school

25.1 %

5.4 %

9.3 %

10.4 %

74.9 %

Non-government school

25.7 %

11.2 %

7.4 %

7.1 %

74.3 %

Religion

Hindu

24.4 %

7.3 %

8.6 %

8.5 %

75.6 %

Muslim

31 %

9.9 %

12.7 %

8.4 %

69 %

Othersa

21.4 %

7.1 %

10.7 %

3.6 %

78.6 %

Ethnicity

Brahmin/chhetri

10.3 %

4.2 %

3.8 %

2.3 %

89.7 %

Dalits

36.3 %

12.7 %

11.8 %

11.8 %

63.7 %

Janjatib

41.5 %

15.6 %

15.1 %

10.7 %

58.5 %

Madhesic

21.6 %

5.2 %

7.8 %

8.6 %

78.4 %

muslim

31 %

9.9 %

12.7 %

8.5 %

69 %

Othersd

26.3 %

6.1 %

9.1 %

11.1 %

73.7 %

a other religion includes Christian, budhism, Jainism

b janjati includes tharu, mandal (dhanuk), magar, limbu

c Madhesi includes Kanu, kalwar, teli, kushwaha, yadav and other terai origin castes

d other ethnicity includes marwadi, Bengali, tamils

Bivariate analysis

In the bivariate analysis, all the explanatory variables except type of school was found to be significantly associated with ever use of tobacco. Male students were more likely to ever use of tobacco than the female students (OR = 2.65;95%CI: 2.01–3.50). Compared to Brahmin/Chhetri students, Janjatis were six times more likely to ever use of tobacco (OR = 6.15; 95 % CI: 3.65–10.36). Muslim students had nearly four times the odds of ever using tobacco than Brahmin/Chhetri students (OR = 3.90; 95 % CI: 2.30–6.61). students whose family members were using tobacco were more likely to ever use tobacco than the students whose family members were not using tobacco (OR = 11.07; 95 % CI: 7.71–15.9). Students having tobacco user friends were nearly 15 times more likely to ever use tobacco than the students having tobacco non-user friends (OR = 14.82; 95 % CI: 10.78–20.36) (Table 3).
Table 3

Different characteristics of respondents and tobacco use (bivariate analysis)

Characteristics

Ever user n (%)a

Non-user n (%)a

p-value

Crude OR (95 % CI)

Sex

 Boys

314 (80.5)

700 (60.9)

<0.01

2.65 (2.01–3.50)

 Girls

76 (19.5)

450 (39.1)

1

Schools

 Government

214 (54.9)

640 (55.7)

0.789

0.97 (0.77–1.22)

 Non-government

176 (45.1)

510 (44.3)

1

Ethnicity

 Brahmin/chhetri

22 (5.6)

191 (16.6)

<0.01

1

 Dalits

37 (9.5)

65 (5.6)

4.94 (2.72–8.99)

 Janjati

85 (21.8)

120 (10.4)

6.15 (3.65–10.36)

 Madhesi

154 (39.5)

554 (48.2)

2.41 (1.49–3.88)

 Muslim

66 (16.9)

147 (12.8)

3.90 (2.30–6.61)

 Others

26 (6.7)

73 (6.3)

3.10 (1.65–5.80)

Knowledge about harmful effect of tobacco use

 No knowledge

128 (32.8)

238 (20.7)

<0.01

3.37 (2.53–4.5)

 Some knowledge

149 (38.2)

153 (13.3)

6.11 (4.54–8.21)

 Good knowledge

121 (31.0)

759 (66.0)

1

Family members using tobacco

 Yes

354 (90.8)

541 (47.0)

<0.01

11.07 (7.71–15.9)

 No

36 (9.2)

609 (53.0)

1

Friends using tobacco

 Yes

338 (86.7)

350 (30.4)

<0.01

14.82 (10.78–20.36)

 No

52 (13.3)

800 (69.6)

1

Exposed at home

 Yes

330 (84.6)

300 (26.1)

<0.01

15.58 (11.49–21.14)

 No

60 (15.4)

850 (73.9)

1

Exposed at Public place

 Yes

374 (95.9)

986 (85.7)

<0.01

3.89 (2.30–6.59)

 No

16 (4.1)

164 (14.3)

1

aIndicates percentage of column

Multivariate analysis

After multivariate analysis, Male students were more likely to be ever tobacco users compared with female students (AOR = 3.2; 95 % CI: 1.4–5.2). Students from Janajati ethnicity were more than five times likely to be ever users of tobacco than those who were Brahmin/Chhetris (AOR = 5.41, 95 % CI: 2.98–7.63). The adolescents who were exposed to smoking at home had higher odds of ever using tobacco compared with those who were not exposed (AOR = 12.12; 95 %:1.69–86.82). Students whose family members used tobacco were twenty times more likely to be ever tobacco user than the students whose family members did not use tobacco (AOR = 20.16; 95 % CI: 1.92–210.30) (Table 4).
Table 4

Association of different variables with tobacco use among adolescent students (Multivariate analysis)

Characteristics

Adjusted Odds ratio (95 % CI)

p-value

Sex

 Boys

3.21 (1.42–5.27)

<0.05

 Girls

1.0

Schools

 Government

1.0

0.29

 Non-government

0.30 (0.03–2.77)

Ethnicity

 Brahmin/chhetri

1

<0.05

 Dalits

1.78 (1.03–2.17)

 Janjati

5.41 (2.98–7.63)

 Madhesi

1.55 (0.89–3.12)

 Muslims

2.31 (1.34–4.65)

 Others

1.98 (0.98–3.34)

Knowledge about harmful effect of tobacco use

 No knowledge

6.17 (0.44–84.92)

0.17

 Some knowledge

5.44 (0.78–29.66)

 Good knowledge

1

Family members using tobacco

 Yes

20.16 (1.93–210.30)

<0.05

 No

1

Friends using tobacco

 Yes

3.78 (1.93–17.85)

<0.05

 No

1

Exposed at home

 Yes

12.12 (1.69–86.82)

<0.05

 No

1

Exposed at Public place

 Yes

1.39 (0.05–3.74)

.24

 No

1

Discussion

Tobacco use is one of the serious and death-causing public health problems all over the world. This study aiming to assess prevalence and factors associated with tobacco ever use among adolescents has described the magnitude and associated factors which have been discussed as follows.

The prevalence of ever use of tobacco in this study was 25.3 % which was more comparable with the findings of a study from Iraq [12]. But it was high compared with a national survey and other studies from Nepal and India [47, 912, 17]. Some studies reported high prevalence of tobacco use than this study [6, 7, 915, 17]. The trend of prevalence of ever use of tobacco seems to be increasing from 7.8 % in 2001, 9.4 % in 2007, 13.9 % in 2008, 20.4 % in 2011 to 25.3 % in this study [4, 711, 1315, 17, 18].

The prevalence of ever as well as current use of tobacco among male students was found more compared to the female students. This finding is comparable with other studies [4, 5, 7, 12].

The prevalence of ever smoker was found 7.7 % in this study which is more in accordance with a national survey [8]. But some other studies show higher prevalence of ever smoker than this study [4, 5, 16, 19, 20]. The prevalence of current tobacco use was 19.5 % in this study. It is more comparable to GYTS 2011 but it is less than the findings of a study from east Nepal [4, 5].

The mean age for tobacco use initiation (smoking and chewing) in our study was found to be in consistency with studies from Dharan, Kathmandu, Noida and Kerala where the mean ages of onset were 13.79, 14.15, 12.4 and 13.2 years, respectively [422].

Sex was found significantly associated with ever tobacco use. There were higher odds of tobacco use among boys as compared with girls. Similar finding was seen in other studies conducted in Nepal and abroad [5, 7, 12, 14, 23]. Ethnicity was significantly associated with ever tobacco use. Tobacco ever use was more likely to exist among Janjatis and Dalits, compared to Brahmins/Chhetris. This finding is comparable with other study [5]. Lower socio-economic status and prevalent illiteracy among Janjatis and Dalits may have some influence on tobacco use among the group. Among Janjatis and Dalits, tobacco use may be culturally acceptable while among Brahmin and Chhetri family, it is considered as forbidden.”

Knowledge regarding harmful effect and health hazard of tobacco use was found significantly associated with ever use of tobacco in other studies [711, 1327]. Bivariate analysis revealed the same finding in this study. But after adjustment for the confounders, result was not in concordance with them. Students whose family members were tobacco users had higher risk of tobacco use relative to those with no family members using tobacco. This finding seems to be consistent with other studies [57, 913, 16, 17]. Students having friends using tobacco were at more risk of ever using tobacco than the students having no friends using tobacco. The same result was seen in other studies [1216]. Friend’s tobacco consumption was found to be a significant link between peer pressure and tobacco use [18].

The present study had few limitations. Even though the participation in the study was completely voluntary with a declaration of non-disclosure of identity and confidentiality, chances of bias may occur in the findings as the data were collected through self-administered questionnaire. The assessment of the tobacco-use status was based entirely upon the response given by the subject believing that false reporting was very unlikely. However, this was not validated by biomarkers. Sample size of the study was small and limited to school-going adolescents of Kalaiya only, hence cannot be generalised. The temporal association between the independent variables and tobacco use could not be established due to cross-sectional nature of the study.

Conclusion

Tobacco use was prevalent among the adolescent students despite the existence of anti-tobacco regulations in the country. Male gender, Janajati, Dalits and Muslims by ethnicity, students having family members and friends using tobacco, students exposed to tobacco at home or at public place were significantly at risk of ever using tobacco. School based interventions and tobacco education are necessary to prevent initiation and cessation of tobacco use. Legislations related to tobacco control should be enforced to decrease availability, accessibility and affordability of tobacco products. Social norms of tobacco use among parents and others at home as well as at public place should be modified to curb the tobacco use among school students.

Further researches are needed to explore the vulnerability of certain ethnic groups towards tobacco use to generate an effective awareness campaign.

Declarations

Acknowledgement

We are heartily thankful to all the school authorities, concerned personnel and students who were behind the completion of this study.

Funding information

There was no funding for the research.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Community Medicine and Public Health, National Medical College
(2)
Kalaiya District Hospital
(3)
Narayani Sub-Regional Hospital

References

  1. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:https://doi.org/10.1371/journal.pmed.0030442.View ArticlePubMedPubMed CentralGoogle Scholar
  2. World Health Organization. MPOWER: A policy package to reverse the tobacco epidemic. Geneva: World Health Organization; 2008.Google Scholar
  3. Sarker et al. Association of smoked and smokeless tobacco use with migraine: a hospital-based case–control study in Dhaka, Bangladesh. Tob Induc Dis. 2013;11:15.View ArticlePubMedPubMed CentralGoogle Scholar
  4. MOHP/WHO. Nepal 2011 country report GYTS & GSPS. Kathmandu: MOHP; 2011.Google Scholar
  5. Pradhan PMS, Niraula SR, Ghimire A, et al. Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: a cross-sectional questionnaire survey. BMJ Open. 2013;3:e002123. doi:https://doi.org/10.1136/bmjopen-2012-002123.View ArticlePubMedPubMed CentralGoogle Scholar
  6. CBS. National population and housing census 2011 national report. Kathmandu: CBS; 2012.Google Scholar
  7. Sreeramareddy CT, Kishore P, Paudel J, et al. Prevalence and correlates of tobacco use amongst junior collegiate in twin cities of western Nepal: a cross-sectional, questionnaire-based survey. BMC Public Health. 2008;8:97.View ArticlePubMedPubMed CentralGoogle Scholar
  8. Pandey MR, Pathak RP, Shrestha S, et al. National Global Youth Tobacco Survey (GYTS) and National Global School Personnel Survey (GSPS) in Nepal 2007. http://www.searo.who.int/entity/noncommunicable_diseases/data/nep_gyts_report_2007.pdf?ua=1.
  9. Chadda RK, Sengupta SN. Tobacco use by Indian students. Tob Induc Dis. 2002;1(2):111–9.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Ministery of Health and population, New Era, ICF International Inc. Nepal demographic and health survey 2011. Kathmandu: MOHP, New Era, ICF International Inc.; 2012.Google Scholar
  11. Kelkar DS, Patwardhan M, Joshi VD. Prevalence ad causalities of tobacco consumption among adolescents: A cross-sectional study at Pune. JAPI. 2013;61:174–8.PubMedGoogle Scholar
  12. Hussain, Abdul Satar. Prevalence and determinants of tobacco use among Iraqi adolescents: Iraq GYTS 2012. Tob Induc Dis. 2013;11:14. doi:https://doi.org/10.1186/1617-9625-11-14.View ArticlePubMedPubMed CentralGoogle Scholar
  13. Singh V, Pal HR, Mehta M, Dwivedi SN, Kapli U. Pattern of tobacco use among school children in National capital territory. Indian J Paeditr. 2007;74:1013–20.View ArticleGoogle Scholar
  14. Muttappallymyalil J, Divakaran B, Thomas T, Sreedharan J, Haran JC, Thanzeel M. Prevalence of tobacco use among adolescents in India. APJCP. 2012;13:5371–4. http://dx.doi.org/10.7314/APJCP.2012.13.11.5371.PubMedGoogle Scholar
  15. Sinha N, Gupta PC, Pednekar MS. Tobacco use among students in Bihar (India). IJPH. 2004;48(3):111–7.Google Scholar
  16. Dereje N, Abazinab S, Girma A. Prevalence and predictors of cigarette smoking among adolescents of Ethiopia: school based cross-sectional study. J Child Adolesc Behav. 2014;3:1. http://dx.doi.org/10.4172/2375-4494.1000182.Google Scholar
  17. Kasiulevicius V, Sapkota V, Filipaviciute R. Sample size calculation in epidemiological studies. Gerontologija. 2006;7(4):225–31.Google Scholar
  18. Awasthi S, Jha SK, Rawat CMS, Pandey S, Swami SS. Correlates of tobacco use among male adolescents in schools of Haldwani, Nainital. HPPI. 2010;33(1):42–9.Google Scholar
  19. Aryal UR, Bhatta DN. Percieved benefits and health risks of cigarette smoking among young adults: insights from a cross-sectional study. Tob Induc Dis. 2015;13:22. doi:https://doi.org/10.1186/s12971-015-0044-9.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Aryal UR, Petzold M, Krettek A. Percieved risks and benefits of cigarette smoking among Nepalese adolescents: A population based cross-sectional study. BMC Public Health. 2013;13:18. http://www.biomedcentral.com/1471-2458/13/187.View ArticleGoogle Scholar
  21. Dhungana RR, Khanal MK, Baniya A. Prevalence of current tobacco use among secondary students in Nepal: A meta-analysis. JCMC. 2013;3(6):1–5.Google Scholar
  22. Narain R, Sardana S, Gupta S, Sehgal A. Age at initiation & prevalence of tobacco use among school children in Noida, India: A cross-sectional questionnaire based survey. Indian J Med Res. 2011;133:300–7.PubMedPubMed CentralGoogle Scholar
  23. Grace SVE, Vijayalakshmi S, Bharathi P, Quarishy ZB. Prevalence of tobacco use among school children, exposure to passive smoking and their knowledge level about tobacco control in Chennai city, Tamil Nadu –A School Based Survey. J Indian Assoc Child Adolesc Ment Health. 2014;10(2):110–31.Google Scholar
  24. Aryal UR, Deuba K, Subedi A, et al. Prevalence and determinants of cigarette students of Kathmandu Valley. Asian J Med Sci. 2010;1:53–8.Google Scholar
  25. Pradeepkumar AS, Mohan S, Gopalakrishnan P, et al. Tobacco use in Kerala: findings from three recent studies. Natl Med J India. 2005;18:148–53.PubMedGoogle Scholar
  26. Martini S, Sulistyowati M. The Determinants of Smoking Behavior among Teenagers in EastJava Province, Indonesia. Health, Nutrition and Population (HNP) Discussion Paper. Economics Of Tobacco Control Paper No. 32. World Bank; 2003. [http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/IndonesiaYouthSmokingFinal.pdf].
  27. Morello P, Duggan A, Adger Jr H, Anthony JC, Joffe A. Tobacco use among high school students in Buenos Aires, Argentina. Am J Public Health. 2001;91:219–24.View ArticlePubMedPubMed CentralGoogle Scholar

Copyright

© Bhaskar et al. 2016

Advertisement