Chapter
Chapter
Chapter
CHAPTER: I
INTRODUCTION
Tobacco is one of the leading eight causes of death in the world. Tobacco is the
largest agent killing 100 million people in 20th century and it is estimated that around
eight million people will die of tobacco every year 2030 A.D. accounting for one
death every three seconds. Eighty per cent of the people among estimated eight
million to die by 2030 likely will belong to the developing countries. It is also
predicted that tobacco will be one of the major causes both for mortality as well as
disability adjusted life years (DALY) in the 21st century. Most of the smokers begin
smoking by early adolescents and generally continue smoking in adult life also. Most
of the chronic adverse health effects may take three to four decades for a full
manifestation. As a result, those who continue smoking have a 50% chance of dying
from tobacco-related disease, and regular smokers have about three time’s higher
death rate than non-smokers at all ages (from young adulthood). (WHO 2008)
Worldwide, tobacco consumption is not just one of the leading cause of preventable
deaths (accounting for more than seven million deaths per year or one death every
second) its global economic burden is estimated to be around 1.4 trillion US Dollars
together with lost productivity (WHO). In 2015, more than 1.1 billion people smoked
tobacco; and rate of smoking in WHO Eastern Mediterranean Region and African
Regions is said to be on the rise. Around 22% of the 15 years and old persons
worldwide are reported to be current smokers. Male generally smoked more than the
female (WHO, 2015).
Nicotine has been consumed in many forms; chewing (e.g. Khaini, Paan, Gutkha),
smoking (e.g. self-prepared bidi from leaves in rural areas of Nepal, commercial bidi,
filtered and non-filtered cigarettes, hookah) and lately nicotine patches, lozenges or
chewing gums as replacement therapy. Mostly, people use as a recreational drug in
the beginning and become habitual in later part of their consumption. It is widely
available throughout the country and most of them probably learn to use it from their
surroundings. From the beginning of the human history nicotine use has existed side
by side. However, its negative consequences on health began to come to notice after
the publication of medical dangers of tobacco by Benjamin Rush in 1798.
2
In Nepal, between 2009 and 2010 around 2491 tonnes of tobacco leaf were produced;
and cigarette production increased from 9970 million sticks in 2006-2007 to 11130
million sticks in 2008-2009. Prevalence of tobacco use or smoking in Nepal was
reported to be 56.5% in men and 19.5% in women (NDHS, 2006). This is higher than
in other countries. The 2007 survey carried out by World Health Organization
(STEPS) showed that the prevalence of smoking among adult females in Nepal was
15%, which is one of the highest in the World Health Organization South-East-Asia
Region. Poor and illiterate sections of the society are more affected by tobacco use.
Eighty six per cent of male smokers and 52% of female smokers smoked
manufactured cigarettes. (WHO STEPS Survey 2007).
In Nepal, among the total population of 26.6 million there are 6.4 million adolescents
(which make up about 24% of the total population) as per census done in 2011.
People aged 15 years to 24 years are 5.3 million accounting for 20% of the total
population. The annual population growth rate was estimated around 1.4%. More than
3
83% of the total population lived in rural area. The average household size was 4.7.
The crude birth rate was 22.17 and the crude death rate 6.8% per thousand
populations. Life expectancy at birth was 64.1 years (64.5 years for females and 6.3
years for male).
Objectives of any study are one of the key elements in research as many things are
described, identified, investigated or evaluated around it. The objectives of a study
are related to the main research questions asked. Objectives can be general objective
and specific objectives. The general objectives broadly summarize the prospects of
the study in general terms and specific objectives follow logically from general
objectives, which is measurable and realistic. The general objective of this thesis is to
study the prevalence of smoking in secondary students in public secondary schools in
Itahari with risk factors and dependence level in this population. The specific
objectives of this thesis are outlined below.
1. This study will give a baseline data about few selected variables about smoking
in public secondary school students and additionally give a percentage of the
students who have a dependence on tobacco consumption.
smoking behaviour from other places and guide us as a pilot study to plan
4. Furthermore, it may help to compare the findings from Itahari to findings from
other places.
The study is mainly focused in Itahari timed, area, financial aspect and research
materials are marked based on the research. The limitations of the study are on
follows:
not enrolled.
3. For this type of study, the sample size is small. All the relevant factors
for the
Current-Smokers: Those 11 & 12 students who have smoked in the last one month
(any amount)
Ever-Smokers: Those 11 & 12 students who has smoked ever in their life time
PSSS: Public secondary school students; those students in public school who are
studying in class 11 and class 12
7
CHAPTER: II
Review of literature literally means understanding the knowledge from its inception,
evolution and current concepts in the identified problem together with the methods by
which the knowledge was generated. Through literature review we come to know
what is known in the field, what is well established, and what are the areas of
inconsistencies or inconclusiveness in the field? If something is well known and
established there is no need to conduct in the same areas, for example, cigarette
smoking significantly increases the chances of cancer. Review of literature also
informs us where there is deficiency or controversy or what is still not known, and
hence it helps to find the useful area to be researched. It also helps to familiarize the
investigator with different methodologies used in the past with its merits and demerits
as well as it also might indicate what methodologies need to be used to generate the
evidence to the required level. The literature review in this thesis highlight briefly
about the historical aspect of the medical aspect of smoking, smoking in adolescence,
theoretical literature on smoking, empirical studies on smoking around the globe in
secondary students, and studies on smoking from Nepal.
The history of smoking probably begins from the antiquity, however, Benjamin Rush,
who was a United States physician, first published the medical dangers of tobacco in
1798. By 1960s, there were enough evidences that tobacco use, or smoking causes
multiple health harms. The rise of smoking in the beginning of 20th century has been
attributed to promotion of tobacco by companies or influencing the policies through
politicians and giving free cigarettes to army personnel as a moral boost. It is
reported to be declining subsequently because of awareness in people of both health
hazards as well as misleading information by the tobacco companies, and subsequent
law-suits against them (Cancer Counsil).
World Health Organization (WHO) defines adolescence as a period from 10-19 years
of age. This period is neither childhood nor adulthood. There is some maturity
compared with earlier phase however full maturity, responsibility, defined roles,
control issues, peer pressure etc. are of special importance. Well handled, they have a
potential to be a fully responsible and mentally healthy individual and if gone astray,
8
it can also impair the future development. This is also the period when most
adolescents experiment drugs including smoking (UNICEF).
This is based on the theoretical literature provided by the Flay, Petraitis & Hu (1999).
It states that any behaviour, including smoking of cigarette, arises in a broad cultural
or social environment with an immediate context where the tendency of the person in
that given situation to perform a certain kind of behaviour and the nature of the
behaviour itself all interact among themselves. All social, attitudinal and
intrapersonal factors may influence at immediate level (decision or intention to smoke
or trial to smoke), proximal level (beliefs in society about normalcy of smoking, belief
about advantage/disadvantage of smoking, or belief about oneself to be able to avoid
smoking), distal level (more attachment to peer group who smoke than to family, less
commitment to conventional values like religion or social alienation, low self-esteem)
and ultimate level (lack of parental warmth or supervision, negative evaluation from
teachers or influence of media, genetic susceptibility or emotional instability). Social
factors may include strain at home or parental separation, negative evaluation from
parents, unconventional values among peers etc. Attitudinal factors may include the
norms in the neighbourhood or in peers, media and advertising depictions of smoking,
low tobacco taxes etc. Intrapersonal factors may include genetic susceptibility, lack
of impulse control, risk-taking behaviour, and looking for sensations mostly, external
locus of control etc. Reviewing the literature, the authors have proposed this ‘Theory
of Triadic Influence’ emphasizing a need to look at all these factors more
comprehensively and have pointed out the major limitations in the theories of
smoking. In their own words, “Most theories and cross-sectional, prospective, and
casual process studies have contained major limitations: a) most addressed only small
portions of the total picture; b) most mediator studies did not test for interactions and
most moderation studies are based on limited theory; and c) most theories did not
discuss how the causal processes might be different for males and females or for
different ethnic groups.”
Jamal et al. (2017) reported 20.2% high school students surveyed from 2011-2016
were tobacco users and 47.2% of the high school students used more than two types
of tobacco. In Poland, the rates of tobacco smoking rose from 15% in 2009 to 24% in
2011 among secondary school students; and for many the initiation of smoking was
9
In Sri Lanka, 19% ever use of tobacco and 10% of smoking (with prevalence of
current smoking by 16% male and 1% female) was reported by students in a survey of
390 students among nine schools. This study further stated that current smoking
status was independently associated with gender and presence of smoker at home (De
Silva & Ekanayake, 2017).
In Greece, 927 high school students between the ages of 15-18 years were examined
using a questionnaire. The mean age of initiation of smoking was 14.4 (± 1.9) years
for boys and 14.9 (± 1.6) years for girls. Nearly one third of boys and slightly more
than one fourth of girls were smokers. Social standard and parental smoking were
cited as main determinants of smoking (Heras, Kritikos, Hatzopoulos, Kritikos, &
Mitsibounas, 2008).
In Saudi Arab, among 819 high school students aged more than 15 years, 20% were
current smokers; mean age of starting smoking was 13.8 years; and influence of
friends (58%) as well as having a smoker in the family were two important factors
that influenced the rate of smoking. Among current users, 61% had tried to quit but
were not successful (Wojtyła-Buciora et al., 2017).
Olumide et al. (2014) studied the predictors of substance use among vulnerable
adolescents (aged 15-19 years) in five cities who were in vulnerable environments
(n=2332). Prevalence of current cigarette smoking was 32.5% in Johannesburg versus
3.7% in Delhi. Mean age of first use of cigarette was 14.4 (± 2) years. Adolescents
who were not going to school were more likely to be current smokers. In
Johannesburg, adolescents currently working for pocket money, absence of a father
figure, and higher peer support were associated with current smoking. In Shanghai
and Baltimore, low scores for caring mother figure predicted cigarette use.
In Zimbabwe, among 650 students with mean age of 16 years, multivariate analysis
showed that smoking was statistically associated with friends smoking cigarette,
being involved in physical fights, alcohol use, marijuana use and having a sexual
intercourse. Other findings were: most of the students started smoking before 13
years of age, Asians students had less prevalence of smoking compared with
Caucasian & African origin, and prevalence of ever-smoking was more in private
school students compared with government school students in age groups 16-19
10
In India, a cross-sectional school-based study done among 4786 students, it was said
that the chances of tobacco use were significantly increased if someone used tobacco
at home or by friends; and if the student were involved in buying tobacco for teachers,
brothers, father/relatives, there would be nearly 11-fold, six-fold and three-fold
increased chance of using tobacco by that student respectively (Narain, Sardana,
Gupta, & Sehgal, 2013). Mahalakshmi (2015) conducted a cross-sectional study on
knowledge on harmful effects of tobacco use among 100 school going adolescents at
rural areas of Tiruvallur district of India. It showed that knowledge score was higher
in females and belonging to nuclear family, 4.3% ever smoked tobacco and higher
intake of tobacco with a history of parental tobacco use.
In China, Zhang, Wang, Zhao, & Vartiainen (2000) found that smoking onset was
most prevalent at 10-14 years of age and it increased with increasing age. It was done
among students of 10-19 years of age (n= 3519) students in four secondary schools in
Henan region using a self-reported questionnaire. It also listed having peers, teacher
and mothers’ smoking were significantly associated with likelihood of tobacco use.
Associated risk factors for initiation or continuation of smoking has been reported by
other studies as well: Parental smoking, peer smoking and marketing strategies by
tobacco companies (Gupta, Sharma, Thakur, Thakur, & Mazta, 2014); (in adults)
Male gender, Bramhan and Chhetri Caste, lack of education, occupation like farming,
poor socioeconomic status (Sah, Pradhan, Subedi, Karki, & Jha, 2016); Authoritarian
and unsupervised parenting (Thomas, Baker, & Lorenzetti, 2007); and smoking
scenes in motion pictures (Sohn & Jung, 2017).Sabnis et al. (2016) suggested that
students from urban areas has increased prevalence of smoking compared with the
students from rural area, however, students from rural areas seemed to use more
smokeless tobacco than the students from urban areas.
packaging and labelling, passed the ‘The Tobacco Product Act 2010’etc (Nepal
Details - Tobacco Control Laws). Under the MPOWER programme, monitoring of
the use of tobacco is also the primary objective. Several studies can be considered
taking place within this framework (MoHP Ministry of Health and Population, 2008).
“A smoker in Nepal would have to spend 3.6% of the national median income to
purchase 10 of the cheapest cigarettes to smoke each day.” About 36.6% of men and
16.7% of female smoke in Nepal; 5.5 % of boys and 0.8% of girls smoke cigarettes in
Nepal; and 10.7% of men and 9% of women die in Nepal due to tobacco (THE
TOBACCO ATLAS).
A study has some basis on which it is done. Mostly, it is based on certain theories or
theoretical frameworks. Health related behaviours, social and organizational aspect of
the study in which how an individual, society, and health systems interact are
generally based on the theoretical framework of the Health Belief Model. Health
Belief Model also can different theories under it specific to the studied problems. A
conceptual framework is usually drawn from certain theories to suit the nature of the
study in consideration. It differs from methodology in that theoretical framework is
more related to the ways of gaining knowledge whereas methodology is more about
the process of conducting the research per se. This study is partially based on the
theoretical literature provided by Flay, Petris and Hu (1999).
13
Exposure
(Parents, siblings, Prevalence of
Age of initiation
peers, teachers, smoking
others)
Level of
dependence
In this study, main emphasis is put on the exposure of smoking either at home or at
school. The mean age of smoking of cigarette smoking was also be noted. The
prevalence of ever smoking as well as the prevalence of current smoking was
recorded. The level of dependence was obtained from a simple, reliable and valid
tool, the Fagerstorm Nicotine Dependence Test. The population was the 11& 12
students of public secondary school in Itahari.
14
CHAPTER: III
RESEARCH METHODOLOGY
So, this research was designed to carry out on the basis of cross sectional and
descriptive type of research method to identify the condition of smoking in school
students regarding decision making of the life.
This study was conducted in 200 students of public secondary schools in Itahari, Janta
secondary school Itahari, Rastriya secondary school Aapgachhi, Janasahayog
secondary school Tarahara, Mahendra secondary school Tarahara, Sharada secondary
school Khanar.
Among seven public secondary schools with classes in Itahari, five of the schools
were randomly selected with lottery method. Among those five randomly selected,
one among eleven classes (minimum of twenty students) and one among twelve
classes (minimum of twenty students) was again randomly selected through lottery
15
method. The researcher approached principals of the selected five schools with
information about the research and request for the permission to conduct the study; all
the queries answered. After permission from the school authorities, researcher was
approach all 11 & 12 classes as selected by the lottery method. Each class was
briefed about the study and also be told about the voluntary nature of participation as
well as provision of confidentiality. Informed verbal consent was taken from the
participants. Approval from the college would be taken prior to undertaking of the
research in different schools.
Two Self-reporting questionnaires used. One contain the socio demographic variables
(except name) and questions pertaining to the exposure of smoking by the students.
Second tool was Fragerstrom Test for Nicotine Dependence for smoking.
After taking permission for research and allotment of each class in rotation, the
researcher was again explaining about the study to the participating students
(including confidentiality). The questionnaires would be distributed to the students
giving half an hour time. Authorities from school during the questionnaire filling and
collection time would be requested to be out of the classroom so that participants can
write without fear.
All the data in questionnaires was transferred to Microsoft Excel Sheet, which in turn
would be transferred to Statistical Package for Social Sciences (SPSS 11.5 version)
software. Mean age of initiation of smoking and frequency of different exposure risk
factors was calculated. The association of parental smoking/sibling smoking/teacher
smoking/peers smoking with current smoking and was calculated.
This screening tool has been used in many researches in people who regularly
consume tobacco because of its ease of using and it has a reliability of 0.88. It
contains six items. This is a self-administered scale and anyone who can read or
write can easily apply it. It gives a score between 0-10. The score of 0-2 is labelled
as very low dependence, 3-4 is labelled as low dependence, 5 as medium dependence,
16
6-7 as high dependence, and 8-10 as very high dependence. It gives a tentative idea
about who needs immediate help. It has been attached in the APPENDIX II.
17
CHAPTER – IV
In this chapter details with the analysis and interpretation of data, which had been
collected from field survey are tabulated in different titles and are analyzed and
interpreted on the basis of percentage to make the presentation more clear and
meaningful.
The habit of smoking begins with the first puff of smoke one takes and it was
important to find out how many students had ever-tried to smoke.
Yes 33 16.5
No 167 83.5
Table 1 shows that among 200 students of 11th and 12th classes, 33 students (16.5%)
tried smoking in lifetime and majority (83.5%) did not.
Among those who ever-tried smoking during their lives, some may continue smoking
and some may discontinue. Students who continue will have more negative health
consequences compared with who quit after tasting it.
18
Yes 29 14.5
No 171 85.5
Table 2 shows that among 200 students, 29 students (14.5%) smoked cigarettes in last
month. Around 86% did not smoke in last one month.
Earlier the age of first smoking more likely for that students to continue smoking as a
habit later in life.
10 1 3.0
13 1 3.0
14 4 12.1
15 9 27.3
16 9 27.3
17 8 24.2
18 1 3.0
Total 33 100
Table 3 shows that among students who ever-tried smoking around 79% of them tried
between 15 to 17 years of age. Twelve percent started smoking at the age of 14 years.
Three percent started smoking at the ages of 10, 13, and 18 years each.
19
Demographic characteristics contain all section like respondent’s age, ethnicity, faith
in religion, gender, class, faculty etc.
Current age reflects the vulnerable population where the smoking habit may be
initiated or continued.
16 24 12.0
17 69 34.5
18 71 35.5
19 36 18.0
Table 4 shows that the current ages of students in years with 35.5% of the students
were 18 years of age and 34.5% were of 17 years of age. Eighteen percent were of 19
years of age and 12% were of 16 years of age.
Ethnicity may inform about the culture of the students. It might possibly affect how
the body of different ethnic groups handles the smoking.
20
70
59
60 57
50 47
Bramhan
40 36
Kshetri
30 Janajati
Madheshi
20 Others
10
1
0
Bramhan Kshetri Janajati Madheshi Others
Figure 1 shows that among respondent students 29.5% were Kshetri, 28.5% were
Janajati, 23.5% were Bramhan, 18% were Madhesi and less than one percent were
others.
Most religions prohibit the use of substances like cigarette smoking. Therefore, faith
in religion might play a protective role in smoking.
No 38 19.0
Table 5 shows that among all respondent students, 81% had faith in religion and 19%
did not.
Most of the literature suggests that males smoke cigarettes more than females. Male
21
140
128
120
100
80 72
Male
60 Female
40
20
0
Male Female
Figure 2 shows that 64% of the participants were female and 36% were males.
Majority of respondents were female.
There were two classes in ten-plus-two classes, class 11 and class 12. Students were
sampled from both classes.
11 100 50.0
12 100 50.0
Table No. 6 shows that there were 50% participants from class 11 and 50%
participants from class 12. Fifty percent respondents were from class 11 & class 12
each.
22
Among the schools chosen, these had four faculties, namely, Education, Management,
Science, and Humanities. It reflects here only the available courses running in the
selected colleges.
Education 81 40.5
Management 80 40.0
Science 20 10.0
Humanities 19 9.5
Table 7 shows that there were around 40% of students selected from Faculties of
Education and Management each, and around 10% each from Faculties of Science
and Humanities.
Joint family, if there is a good harmony, will have more people to support students
including guidance in remaining abstinence from smoking, however, if family
members smoke, it increases the exposure to more people at home for smoking.
140
120
120
100
80
80
Nuclear
60
Joint
40
20
0
Nuclear Joint
23
Figure 3 shows that 60% of students belonged to nuclear family and 40% belonged to
joint family.
Living alone during adolescence may keep them out of sight from parental discipline
that may encourage them to start smoking especially if peers smoke.
Alone 15 7.5
Table 8 shows that 33% students lived with only one parent, 19% lived with both
parents, 9.5% lived with relatives, 7.5% lived alone, and 4.5% lived with friends.
Majority respondents lived with only one parent.
Some literature has suggested that father’s occupation as a risk factor for smoking of
cigarettes and some has not shown any association.
24
No work 9 4.5
Farmer 76 38.0
Others 40 20.0
Table 9 shows that 38% of the fathers were involved in farming, 20% in others,
13.5% in government job (non-force), 13% in private sector, 11% in army or police,
and 4.5% were unemployed. Majority of father’s occupation was farming.
Some literature has suggested that mother’s occupation as a risk factor for smoking of
cigarettes and some has not shown any association.
25
No work 93 46.5
Farmer 54 27.0
Others 32 16.0
Table 10 shows that 46.5% of students’ mothers were unemployed, 27% were
involved in farming, 16% in others, 6% in private sector, 4.5% in government job,
and none of the mothers were working in army or police. Majority of the respondent’s
mother did not work.
Study suggested that students from urban background tend to smoke more compared
with rural background, and students from rural background tend to use smokeless
tobacco compared with the urban background.
Table 11 shows that 53.5% of the students were from rural background and 46.5%
were from urban background. Slightly more than 50% came from the rural
26
background.
Family member is the main and first part of the adolescent students and friends is the
second part. Smoking by close friends and family members were strong influencing
factors for tobacco use of adolescent students.
Presence of smoker in the family provides the early exposure to smoking to students.
Yes 59 29.5
No 141 70.5
Table 12 shows that 70.5% of the students did not have anyone smoking in the family
and 29.5% had at least one member as smoker in the family.
Smoking by father provides a negative role model for students regarding smoking.
Yes 44 22.0
No 156 78.0
Table 13 shows that majority of the students’ fathers (78%) did not smoke and 22% of
the students’ father smoked father. Higher percentage of did not smoke student’s
father.
27
Smoking by mother provides a negative role model for students regarding smoking.
Yes 8 4.0
No 192 96.0
Table 14 shows that almost all mothers of the students (96%) did not smoke except
four percent of the mothers who smoked.
Smoking other than parents in the family also exposes the students to smoking
behavior which is also a risk factor for the smoking of the students.
Yes 50 25.0
No 150 75.0
Table 15 shows that 75% of the other family members (other than parent) did not
smoke cigarettes and 25% smoked cigarettes.
As the number of smokers increases in the family, there is more exposure to smoking.
Smoking by respected members as well as brothers and sisters may give the
impression to the students that smoking is an acceptable behavior.
28
No 180 90.0
Uncle
Yes 20 10.0
No 197 98.5
Aunt
Yes 3 1.5
No 186 93.0
Elder brother
Yes 14 7.0
No 199 99.5
Elder sister
Yes 1 0.5
No 191 95.5
Cousins
Yes 9 4.5
No 191 95.5
Yes 54 27
Table 16 shows that 90% of the uncles of the students did not smoke cigarettes and
10% did smoke. Nearly all aunts (98.5%) did not smoke cigarettes and 1.5% did not.
Ninety three percent of elder brothers did not smoke cigarettes and three percent
smoked. Almost all elder sisters (99.5%) did not smoke cigarettes. Among cousins
(brothers and sisters) and others 95.5% did not smoke cigarettes each.
Adolescents are more influenced by friends, especially close friends, than parents.
Smoking by close peers is a recognized risk factor for smoking during adolescence.
29
Yes 47 23.5
No 153 76.5
Table 17 shows that 76.5% of the close friends did not smoke cigarettes and 23.5%
smoked. Majority of the friends did not smoke.
As the numbers of friends increase so the chances of more peer influence increase.
Lesser the number of friends who smoke, probably less influenced a student would
be.
3 19 35.2
4 7 13.0
5 4 7.4
8 1 1.9
10 1 1.9
12 1 1.9
13 1 1.9
Table 18 shows that 35.2% students had three friends who smoked, 27.8% had two
30
friends who smoked, 13% had four friends who smoked, 9.3% had one friend who
smoked, and 7.4% had five friends who smoked. Nearly 2% students had 8, 10, 12,
and 13 friends each who smoked cigarettes.
If a student is offered a cigarette compared with no one offers him, there may be
increased chances of starting smoking. When a close friend offers cigarettes, a
student might find it difficult to reject that offer not to lose the friendship, which puts
the students at higher risk.
Yes 32 16.0
No 168 84.0
Table 19 shows that 84% of the students were not offered cigarettes by close friends
and 16% were offered cigarettes by close friends. Close friends did not offer many
respondents cigarettes.
Teachers are very important role models in schools. When a student sees a teacher
smoking who is supposed to guide him towards more healthy behavior that may
adversely affect the students’ behavior.
31
Yes 39 19.5
No 161 80.5
Table 20 shows that 80.5% of the students did not see their teacher smoking and
19.5% saw their teacher smoking.
People have different preferences for smoking that is influenced by availability, cost,
and what is mostly being practiced in the locality.
Cigarette 24 82.8
Bidi 0 0.0
Cigar 1 3.4
Other 4 13.8
Total 29 100
Table 21 shows that most of the students smoked cigarettes (82.8%) and none of the
students smoked bidi. One student (3.4%) smoked cigar and four students (13.8%)
smoked other types.
20 19
18
16
14
12
10
10 No
8 Yes
0
No Yes
Figure No. 4 shows that 65.5% students had easy access to cigarettes and 34.5% had
difficulty in getting cigarettes.
Those students who smoke have to obtain it from one or the other ways. Some may
buy or receive from others.
Others 2 6.89
Total 29 100
Table 22 shows that 58.6% of the students bought cigarettes from a shop, 31% of the
33
students were offered by friends, 3.4% got it from family and 6.8% obtained it by
other means.
Those students who smoke, some may buy in small amounts at a time or in large
quantities. Those students who are more habitual may buy in large amounts.
Others 1 3.4
Total 29 100
Table 23 shows that 44.8% of the students who were current smokers bought one
cigarette at a time, 41.3% bought in packs, 10.3% never bought cigarettes, and 3.4%
did not reply to this question in a specific way.
Constant fights at home reduce students’ self-esteem and frustration that might lead to
smoking problem. If the home environment is harmonious, a student finds it easier to
share his problems in studies or other areas.
34
Yes 70 35.0
No 130 65.0
Table 24 shows that 65% of the total students who participated in the study reported
no fights in the family and 35% reported fights in the family.
Research has shown that children or adolescents do best when parenting style is
neither too strict nor loose but optimum (firm in limit setting but understanding and
supportive mostly).
6.5
44 With no discipline
Figure No. 5 shows that 49.5% students perceived that their parents raised them with
optimal discipline, 44% perceived that their parents raised them with strict discipline,
and 6.5% perceived that their parents did no ensure discipline.
35
4.4.7 Every day ever smoked cigarette for last 30 days by students
Smoking may be occasional to begin with but gradually with continued use, one may
begin to smoke daily.
Table No. 25: Smoking of cigarettes every day in last 30 days by students
Every day ever smoked cigarette in last 30 days No. of smoker Percent
Yes 29 14.5
No 171 85.5
Table 25 shows that all of the current smokers who smoked at least one cigarette in
last 30 days continued to smoke daily; it was 14.5% of the total respondent students.
Students smoke in different places like at home, school, houses, in social events or
places.
36
I smoke 29 14.5%
At home 4 13.8
At school 4 13.8
Total 29 100
Table 26 shows that among current smokers, 41.4% of students smoked at friends’
house and 17.2% smoked in sports events, parties or other social events. Students
smoked at home, at school, and in public places 13.8% each.
Some the current smokers want to quit smoking. The desire to quit smoking is an
important finding because if students can be attended during this period there is more
probability of motivational intervention being effective than other period.
37
Yes 18 62.1
No 11 37.9
Total 29 100
Table 27 shows that 62.1% of the current smokers wanted to quit smoking and 37.9%
of the current smokers did not want to quit smoking.
Smokers have different reasons for starting smoking. Some of them start after having
problem either at school or at home or due to stress. In the early phase of smoking, if
the reason for which smoking was started can be addressed, it is helpful in quitting
smoking.
12
11
10
8
7
Loneliness
6
6 Family Problem
5
Stress
4
Others
0
Loneliness Family Problem Stress Others
Figure No 6 shows that nearly 38% could not report exact reason for starting
smoking, 24.1% cited loneliness, 20.6% cited family problems, and 17.2% cited stress
as reasons for starting smoking respectively.
38
Coughing 7 24.13
Tiredness 1 3.44
Total 29 100
Table 28 shows that among current smokers nearly 45% of students reported other
health problems (however students did not specify the symptoms in Performa) caused
by smoking. Nearly one fourth each reported coughing and feeling of not getting
enough air, and 3.4% each reported tiredness and premature wrinkles as health
problems caused by smoking.
Printed, audio, visual, and audio-visual media are also important sources of exposure
to cigarette smoking. One study done in Nepal also has shown that exposure to
smoking through reading or listening in media also adversely affects students.
39
No 17 8.5
Table 29 shows that 91.5% of all students were exposed to media involving cigarette
smoking either in reading form or listening form.
There may be more than one source of exposure in media about cigarette smoking, for
example, magazines, newspaper, television, radio etc.
11
News Papers
4.5
Magazines
Radio
Others
TV
Figure No. 7 shows that 70% of the total students had exposure to cigarette smoking
by television, 11% had exposure through magazines, 9.5% had exposure through
newspaper, 4.5% had exposure through radio, and 5% had exposure through other
means.
40
Some smokers have a belief that smoking causes weight loss, and especially if these
smokers have more than desired weight, they may erroneously continue smoking.
Table No. 30: Perception of students regarding Smoking makes lose weight
I disagree 40 20.0
I agree 45 22.5
Table 30 shows that of the total students, 22.5% agreed and 22% definitely agreed
that smoking makes lose weight, however, 20% disagreed and 11.5% definitely
disagreed that smoking makes lose weight.
Smoking costs money. The more the number of cigarette smoking the more
expenditure on smoking.
41
Rupees.
50 1 4.76
70 1 4.76
100 3 14.28
150 4 19.04
200 6 28.57
300 6 28.57
350 3 14.28
400 5 23.80
500 4 19.04
600 1 3.44
1000 2 9.52
2000 1 3.44
Table 31 shows that of the total students, per week 28.57% students each spent 300
rupees and 200 rupees, 23.8% students spent 400 rupees, and 19% each spent 500
rupees and 150 rupees on smoking. On smoking, around 14% students spent 350
rupees and another 14% students spent 100 rupees per week, 9.5% students spent
1000 rupees per week, around 9% spent between 50 to 70 rupees per week, and 3.4%
students spent 2000 rupees per week. Around 15% students did not spend money on
smoking.
42
During childhood and adolescence, peer influence is high and many a time the
perception that circulates in the friends’ circle may not be accurate.
40
Harmful
No effect
Good
65%
Figure No. 8 shows that of the total 200 students, 88% thought that smoking is
harmful to health, 8% thought that smoking has no effect on health and four percent
thought that smoking has a good effect on health.
The shorter the time interval after waking to the first cigarette smoking, the more
chances of habitual way of smoking. The longer the duration, better the control of
smoking.
43
Table No. 32: Minutes after waking to the 1st cigarette smoking
Total 29 100
Table 32 shows that among current smokers, 48.3% students smoked their first
cigarette after five to thirty minutes, 37.9% smoked after 31-60 minutes after waking
up, and nearly 14% smoked their first cigarette within five minutes after waking up.
If a person is not habitual in smoking, one can control the desire to smoking in
forbidden places. The more one becomes habitual, the more difficult it becomes for
that person to let go of smoking in forbidden places.
Yes 8 27.58
No 21 72.41
Total 29 100
Table 33 shows that 72.4% of current smokers did not have any difficulty and nearly
28% had difficulty in refraining from smoking in forbidden places like temple,
schools etc.
The more habitual the person is on smoking, the more difficulty they experience in
giving up cigarette smoking in the morning than at other times.
44
Table No. 34: Which cigarette would students hate to give up?
Total 29 100
Table 34 shows that 72% of the current smokers would rather give up smoking at
other times, however, nearly 28% of the current smokers would hate to give up
smoking in the morning.
More a person becomes dependent on smoking the more number of cigarettes one
begins to smoke.
Total 29 100
Table 35 shows that 93% of the current smokers smoked ten or less than ten cigarettes
a day and around 7% of the current smokers smoked between eleven to twenty
cigarettes a day. None of the current smokers smoked more than twenty cigarettes a
day.
45
The more dependent a person is on smoking, the more frequently that person would
smoke in the morning.
Yes 12 41.4
No 17 58.6
Total 29 100
Table 36 shows that 58.6% of the current smoker students did not frequently smoke in
the morning and around 41% of the current smoke students frequently smoked in the
morning compared with other times of the day.
Generally, when a person is not dependent on smoking, one can give up smoking in
difficult places or situations. However, if someone is dependent on smoking, they
would find it difficult to give up smoking even when they are sick in bed.
Table No. 37: Smoking of cigarettes despite falling sick in bed by students
No (Score 2) 26 89.65
Total 29 100
Table 37 shows that nearly 90 % of the current smoker students could give up
smoking if they fall sick in bed, however, around 10% current smoker students would
not give up smoking even if they fall sick in bed.
46
The Fagerstrom Test for Nicotine Dependence gives the aggregate score used for
screening of people with nicotine dependence with good reliability and validity. The
higher the score the more likely it is for that person to become dependent for nicotine.
Total 29 100
Table 38 shows the dependence level of the students who are current smokers.
Around three fourths of the students (48.5% of very low dependence and 34.5% of
low dependence) were not at high risk for very habitual pattern of smoking and nearly
seven percent (3.4% each from high dependence and very high dependence) need
urgent counseling regarding smoking. Around 10% in the middle range would
definitely benefit from counseling regarding smoking.
The thesis was submitted to the Janata Multiple Campus and permission to conduct
study was obtained. All the government schools in Itahari were listed and 3 schools
were selected with lottery method. The selected government schools were
approached for permission and introduction about the research was briefed. In each
school, one 11 class and one 12 class were selected. All the students who were
47
present during the class were taken and to ensure confidentiality, the concerned
personnel from that school were kept out of the classroom. In each class, the
researcher introduced her and briefed about the study and explained about the
voluntary nature of participation and confidentiality of their information. The
Performa was distributed among the students and filled questionnaires were taken
back. Researcher thanked the participants for their voluntary participation.
All the collected data were transferred into tabular figure form and interpreted. There
was a total of 200 participants from all selected schools, 100 students from class 11
and 100 students from class 12. There were 81 students studying Faculty of
Education, 80 students studying Faculty of Management, 20 students studying Faculty
of Science, and 19 students studying Faculty of Humanities. Among 200 students,
128 students (64%) were female and 72 students (36%) were male. Participant
students’ age ranged from 16 to 19 years with 70% of the them being 16 and 17 years
of age. Among respondent students 29.5% were Kshetri, 28.5% were Janajati, 23.5%
were Bramhan, 18% were Madhesi and less than one percent were others. Sixty
percent of students belonged to nuclear family and 40% belonged to joint family.
Thirty three percent students lived with only one parent, 19% lived with both parents,
9.5% lived with relatives, 7.5% lived alone, and 4.5% lived with friends. There were
53.5% of the students from rural background and 46.5% from urban background.
Thirty eight percent of the students’ fathers were involved in farming, 20% in others,
13.5% in government job (non-force), 13% in private sector, 11% in army or police,
and 4.5% were unemployed. There were 46.5% of students’ mothers unemployed,
27% were involved in farming, 16% in others, 6% in private sector, 4.5% in
government job, and none of the mothers were working in army or police. Nearly
half of the students perceived that their parents raised them with optimal discipline,
44% perceived that their parents raised them with strict discipline, and 6.5%
perceived that their parents did no ensure discipline. Sixty five percent of the total
students who participated in the study reported no fights in the family and 35%
reported fights in the family. Among all respondent students, 81% had faith in
religion and 19% did not.
Among 200 students of 11th and 12th classes, 33 students (16.5%) tried smoking in
lifetime and majority (83.5%) did not. Among 200 students, 29 students (14.5%)
smoked cigarettes in last month. Around 86% did not smoke in last one month.
48
Those students who ever-tried smoking, around 79% of them tried between 15 to 17
years of age. Twelve percent started smoking at the age of 14 years. Three percent
started smoking at the ages of 10, 13, and 18 years each.
Nearly 30 % of the 200 students had someone in the family who smoked cigarettes.
Twenty two percent of the students’ fathers, eight percent of the students’ mothers,
ten percent of the students’ uncles, three percent of the students’ aunts, seven percent
of the students’ elder brothers, around five percent of the students’ cousins smoked
cigarette. Less than one percent of the students’ sisters smoked cigarette. Among 200
students, only 25% of the any other relatives other than parents smoked cigarette in
the family. Nearly 24% of the close friends of the students smoked cigarette and 76%
of students had between two to four friends who smoked. Sixteen percent of the
participant students were offered cigarette by a close friend. Around 20% of the 200
students saw their teachers smoking cigarette.
Among 29 current smokers, most of the students (82.8%) smoked cigarettes and less
smoked other types. Nearly 38% could not report exact reason for starting smoking,
24.1% cited loneliness, 20.6% cited family problems, and 17.2% cited stress as
reasons for starting smoking respectively. The mean age of initiation of smoking was
15.56 years with standard deviation of 1.46 and range from 10 to 18 years. Nineteen
students out of 29 current smokers (around 66%) reported that it was easy for them to
get cigarettes; 58.6% of the students bought cigarettes from a shop, 31% of the
students were offered by friends, 3.4% got it from family and 6.8% obtained it by
other means. Among current smokers, 44.8% of the students bought one cigarette at a
time, 41.3% bought in packs, 10.3% never bought cigarettes, and 3.4% did not reply
to this question in a specific way. All the 29 current smokers among 200 participants
smoked cigarette every day in last month; 93.1% students smoked two to five
cigarettes per day, 6.9% smoked 11-20 cigarettes per day, and none of the students
smoked more than 20 cigarettes per day. Those who were smoking, 41.4% of
students smoked at friends’ house and 17.2% smoked in sports events, parties or other
social events. Students smoked at home, at school, and in public places 13.8% each.
About 62% of the current smokers wanted to quit smoking and 38% of the current
smokers did not want to quit smoking. Nearly 45% of students reported other health
problems (however students did not specify the symptoms in Performa) caused by
smoking; about one fourth each reported coughing and feeling of not getting enough
49
air, and 3.4% each reported tiredness and premature wrinkles as health problems
caused by smoking.
Of the total students (200), 22.5% agreed and 22% definitely agreed that smoking
makes lose weight, however, 20% disagreed and 11.5% definitely disagreed that
smoking makes lose weight; 88% thought that smoking is harmful to health, 8%
thought that smoking has no effect on health and four percent thought that smoking
has a good effect on health. Of the total students, per week 28.57% students each
spent 300 rupees and 200 rupees, 23.8% students spent 400 rupees, and 19% each
spent 500 rupees and 150 rupees on smoking. On smoking, around 14% students
spent 350 rupees and another 14% students spent 100 rupees per week, 9.5% students
spent 1000 rupees per week, around 9% spent between 50 to 70 rupees per week, and
3.4% students spent 2000 rupees per week. Around 15% students did not spend
money on smoking.
Near about 92% of all 200 students were exposed to media involving cigarette
smoking either in reading form or listening form; 70% of the total students had
exposure to cigarette smoking by television, 11% had exposure through magazines,
9.5% had exposure through newspaper, 4.5% had exposure through radio, and 5% had
exposure through other means.
Around three fourths of the students among current smokers (48.5% of very low
dependence and 34.5% of low dependence) were not at high risk for very habitual
pattern of smoking and nearly seven percent (3.4% each from high dependence and
very high dependence) need urgent counseling regarding smoking. Around 10% in
the middle range would benefit from counseling regarding smoking.
50
CHAPTER – V
This chapter presents the summary of the study with its major findings, conclusion
and recommendations for improvement and future research study.
5.1 CONCLUSION
2. The mean age of initiation of smoking was 15.56 years with standard
deviation of 1.46 and range from 10 to 18 years.
3. In 30% of the 200 students someone smoked in the family. Twenty two
percent of the students’ fathers, eight percent of the students’ mothers, ten
percent of the students’ uncles, three percent of the students’ aunts, seven
percent of the students’ elder brothers, around five percent of the students’
cousins smoked cigarette. Less than one percent of the students’ sisters
smoked cigarette. Among 200 students, only 25% of the any other relatives
other than parents smoked cigarette in the family. Nearly 24% of the close
friends of the students smoked cigarette and 76% of students had between two
to four friends who smoked. Sixteen percent of the participant students were
offered cigarette by a close friend. Around 20% of the 200 students saw their
teacher smoking cigarette.
5.2 Recommendation
The recommendation for improvement and future research area on the basis of
51
1. The laws and regulations should be enforced therefore the shops near schools
cannot sell cigarettes to students.
2. The number of shops distributing cigarettes should be controlled. Namely, not
all the shops are allowed to sell cigarettes.
3. More public relations related to Tobacco Control Laws should be provided for
people.
4. The responsible officers should pay more attention to the laws implementation
and regularly check about the shops distributing cigarettes to the students aged
below 18 years old.
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56
APPENDIX–I
TRIBHUVAN UNIVERSITY
FACULTY OF EDUCATION
Itahari, sunsari
Questionnaire
8. You live…
a) Alone b) With only one parent
c) With both parents d) With relatives e) with friends
9. What is your father’s occupation ?
a) Yes b) No
5. Please tick all that apply, yes
a) Uncle b) Aunt c) Elder brother
d) Elder sister e) Cousin brother or sister or both f) Others
6. Do your close friends smoke cigarettes?
a) Yes b) No
7. If yes, specify the number of smoker……..
8. Have your close friend ever offered you a cigarette ?
a) Yes b) No
58
a) Yes b) No
Other history of smoking
a) Yes b) No
6. How do you overall feel regarding how your parents raised you?
12. What kind of health problem do you feel because of cigarette smoking ?
13. Have you ever read or listen to cigarette advertisements in the last month (30
days)?
a) Yes b) No
14. Where did you ever read or listen to cigarette advertisements ?( You can
choose more than one )
16. How much money do you spend in a week ? (only pocket money, not
including for school goods)
APPENDIX–II