Conceived and designed the experiments: GS PCG KV. Analyzed the data: PCG. Wrote the paper: GS EN PCG KV.
The authors have declared that no competing interests exist.
In response to India's growing tobacco epidemic, strategies are needed to decrease tobacco use among Indian youth, particularly among those who are economically disadvantaged. The objective of this study was to assess the effectiveness of a school-based life-skills tobacco control program for youth of low socio-economic status in Mumbai and the surrounding state of Maharashtra. We hypothesized that compared to youth in control schools, youth exposed to the program would have greater knowledge of effects of tobacco use; be more likely to take action to prevent others from using tobacco; demonstrate more positive life skills and attitudes; and be less likely to report tobacco use.
Using a quasi-experimental design, we assessed program effectiveness by comparing 8th and 9th grade students in intervention schools to 8th grade students in comparable schools that did not receive the program. Across all schools, 1851 students completed a survey that assessed core program components in early 2010. The program consisted of activities focused on building awareness about the hazards of tobacco, developing life skills, and advocacy development. The primary outcome measure was self-reported tobacco use in the last 30 days.
Findings indicate that 4.1% of 8th grade intervention students (OR = 0.51) and 3.6% of 9th grade intervention students (OR = 0.33) reported using tobacco at least once in the last 30 days, compared to 8.7% of students in the control schools. Intervention group students were also significantly more knowledgeable about tobacco and related legislation, reported more efforts to prevent tobacco use among others, and reported stronger life skills and self-efficacy than students in control schools. Limitations to the study include schools not being randomly assigned to condition and tobacco use being measured by self-report.
This program represents an effective model of school-based tobacco use prevention that low-income schools in India and other low- and middle-income countries can replicate.
Tobacco use is expected to contribute to an increasing proportion of the global disease burden
India represents an important setting for such efforts, as the second largest country in the world and with prevalent use of multiple forms of tobacco. In 2010, one million Indians were expected to die from tobacco-related causes
There is a strong evidence base for tobacco use prevention interventions in developed countries
This paper describes such an evaluation. Specifically, this study evaluated a tobacco use prevention program already in place in India, implemented by the Salaam Bombay Foundation (SBF). The aim of this program is to reduce tobacco use initiation and prevalence among youth from low socio-economic backgrounds in Mumbai and more broadly, in the Indian state of Maharashtra. SBF is a non-profit organization established in 2002 with the vision of “empowering children to live their life free from the threat of tobacco and to become confident to lead tomorrow's India”
The purpose of this paper is to describe the results of an assessment of the effectiveness of the SBF program by comparing knowledge, attitudes and life skills, and tobacco use patterns among 8th and 9th grade students in SBF schools with 8th grade students in schools not receiving the SBF program. We hypothesized that compared to students in control schools, students in schools receiving the SBF program will be: (1) more knowledgeable about products containing tobacco and about tobacco control legislation; (2) more likely to take action to prevent others from using tobacco; (3) more likely to demonstrate positive life skills and attitudes; and (4) less likely to report using tobacco in the last 30 days. This important study has the advantage of examining a program already being implemented on a large scale, with demonstrated infrastructure already in place.
This study used a quasi-experimental design to assess the efficacy of the SBF program in improving students' life skills and self-efficacy, actions against tobacco, and tobacco use. SBF leadership requested an independent evaluation of its program from this investigator team. In early 2010, surveys were administered to 8th grade and 9th grade students in randomly selected classes in schools receiving SBF programs, and to 8th grade students similarly selected in control schools not receiving the SBF program. We compared the two 8th grade conditions in order to estimate the program's effect after one year of intervention, and compared the 8th grade control schools and 9th grade intervention schools to estimate the its effect after two years of exposure to the program, while controlling for age, gender, and mother's education as an indicator of socioeconomic status.
The mission of SBF is to guard the next generation from the harmful effects of tobacco by working with children from resource-poor schools that cater to low socio-economic status populations, to reduce tobacco use initiation, and to foster the development of life and advocacy skills among these students. Program activities were funded by income from corpus funds of SBF; 30 full-time staff members delivered the program to the 8th and 9th grades across all schools participating in the program. During the 2010–11 academic year, SBF provided in-school programming to 49,866 children aged 10–17 from 147 government-run schools in Mumbai. Since its inception in 2002, SBF has trained 453,221 children and 16,029 teachers from schools in 17 districts of Maharashtra state in India.
The SBF program is designed to assist children in making informed decisions using valid information and the relevant life-skill tools to deal with life's challenges. The immediate objectives of the program include to: reduce initiation of tobacco use among participating children; create awareness on the harmful health consequences of tobacco and of misleading tobacco advertisements; create awareness of tobacco control legislation; build advocacy skills; provide sports and arts platforms to inculcate the concept of team work; develop leadership skills and create positive role models among peers; and build confidence, decision making skills, refusal skills and communication skills in order to handle peer pressure to stay away from tobacco.
The SBF program targets and objectives extend across a continuum from building awareness about the hazards of tobacco use among students in all participating schools, to developing life skills through a range of experiential platforms. These efforts are promoted through in-school programs focused in the first year (for 8th graders) on awareness building, and in the second year (for 9th graders) on advocacy training. Additional after-school programs offer “academies” that use the vehicles of sports, arts and journalism to build confidence, peer relations, and refusal skills. During Year 1, the “super army” offered within the classroom focuses on creating awareness of tobacco, as well as personality development that focuses on improved communication, refusal skills, handling peer pressures, and habit formation. In Year 2, students are trained to work with different civic authorities to support the implementation of the prevailing tobacco control law. Students interact with the police, the media, and health departments, and use religious and cultural festivals to involve the communities.
All sessions are divided into classroom and out-of-classroom activities. The classroom-based sessions were conducted once or twice a month for all children, with the aim of providing each child a minimum exposure of 10 one-hour classroom sessions per year. Attendance was tracked, and a minimum of 70% attendance was required for any session to be conducted; in cases where attendance was below 70%, the session was postponed and offered at a later date. The out-of-classroom activities were conducted regularly, two to three times a week with a focus on creating peer leaders. In this paper, we examine the impact of the program for 8th graders after one year of exposure to the program, and for 9th graders exposed to two years of in-classroom programming.
We conducted a survey of students in schools receiving the SBF intervention, including 8th grade students from 20 schools and 9th grade students from 16 different schools, and from 8th grade students in 23 similar schools not receiving the SBF program. All schools were municipally funded, to be distinguished from other types of schools relying on private funds; accordingly, the schools in both groups represent similar student populations from low-income communities. One classroom per school was randomly selected to participate in the survey. Each classroom included between 25 and 70 students; approximately 30 students per class were randomly selected to participate in the survey. All students invited to participate responded to the survey. Approximately 5% of 8th grade students in both conditions and 14% of 9th grade students were absent from class the day of the survey.
We developed a structured questionnaire with 73 questions, without any skip or branch patterns. The survey and data collection methods were pre-tested in two SBF schools and two non-SBF schools that were not part of the study. The survey was translated and administered in Hindi and Marathi, depending on the language of instruction within the school. The questions and instructions were read aloud to the class and responses were marked by each student on the questionnaire. This survey administration method was preferred over a fully self-administered format given the literacy levels of the students. Data were collected in February 2010, which marks the end of the academic calendar in these schools. The survey administrators were trained in standard data collection methods, and were independent of the SBF staff. The survey was completely anonymous.
The survey was designed to assess primary and secondary outcomes of participation in the SBF program, as outlined in the hypotheses. To the extent possible, items were adapted from existing instruments
Agree/Yes N (%) | 8th grade control vs. 8th grade Intervention | 8th grade control vs 9th grade Intervention | |||||
8th Grade Control | 8th Grade Intervention | 9th Grade Intervention | Adjusted Odds Ratio | 95% CI | Adj Odds Ratio | 95% CI | |
Does gutkha contain tobacco?(%yes) | 194 (28.2) | 292 (44.2) | 224(44.7) | 2.2 | 1.7–2.8 | 2.1 | 1.6–2.8 |
Does mishri contain tobacco? (%yes) | 379 (55.1) | 403 (61.0) | 368(73.5) | 1.3 | 1.0–1.6 | 1.9 | 1.4–2.5 |
Which product is found in gutkha, mava, mishri, khaini, pan masala, cigarette, bidi? |
226 (32.9) | 497 (77.3) | 417(83.9) | 7.4 | 5.7–9.6 | 22.8 | 15.6–33.4 |
Is there a law in Mumbai which stops people from smoking in public places? (%yes) | 374 (54.3) | 414 (62.6) | 347(69.3) | 1.4 | 1.1–1.8 | 2.0 | 1.5–2.7 |
In Mumbai is it against the law to sell tobacco to minors under age 18? (%yes) | 437 (63.5) | 465 (70.3) | 431(86.0) | 1.5 | 1.1–1.9 | 3.5 | 2.5–5.0 |
Response 1: Nicotine; Response 2: Others.
Odds ratios adjusted for age, gender, mother's education and school.
Agree/yes N (%) | 8th Grade Control vs 8th Grade Intervention | 8th Grade Control vs. 9th Grade Intervention | |||||
8th Grade Control | 8th Grade Intervention | 9th Grade Intervention | Adj Odds Ratio | 95% CI | Adj Odds Ratio | 95% CI | |
Do you think you could help a friend to stay away from trying gutkha, mava, etc.? | 529 (77.0) | 554 (83.8) | 437(87.2) | 1.5 | 1.1–2.0 | 2.5 | 1.7–3.6 |
In last year, have you worked to prevent or reduce tobacco use in your neighbourhood? | 124 (18.1) | 148 (22.4) | 106(21.2) | 1.4 | 1.1–1.9 | 1.1 | 0.8–1.5 |
In last year, have you worked to prevent or reduce tobacco use in your school? | 217 (31.5) | 356 (53.9) | 360(71.9) | 2.8 | 2.2–3.5 | 4.6 | 3.4–6.1 |
It is none of my business to tell other people not to use tobacco. | 351 (51.1) | 393 (59.5) | 300(60.3) | 1.5 | 1.2–1.8 | 1.5 | 1.1–2.0 |
Odds ratios adjusted for age, gender, mother's education and school
Agree/Yes N (%) | 8th Grade Control vs. 8th Grade Intervention | 8th Grade Control vs. 9th Grade Intervention | |||||
8th Grade Control | 8th Grade Intervention | 9th Grade Intervention | Adj Odds Ratio | 95% CI | Adj Odds Ratio | 95% CI | |
I believe my life has no purpose | 40′ (58.2) | 257 (38.9) | 184(36.7) | 0.45 | 0.4–0.6 | 0.40 | 0.3–0.5 |
Nobody cares what my opinion is | 435 (63.3) | 341 (51.7) | 274(54.8) | 0.66 | 0.5–0.8 | 0.65 | 0.5–0.9 |
I don't know if I will study till 10th (grade). | 565 (82.0) | 421 (63.8) | 349(69.8) | 0.40 | 0.3–0.5 | 0.49 | 0.4–0.7 |
I worry about my ability to support myself financially in the future | 591 (86.0) | 467 (70.8) | 349(69.6) | 0.38 | 0.3–0.5 | 0.32 | 0.2–0.5 |
I don't know what will happen to me after I finish 10th (grade) |
399 (58.0) | 422 (63.8) | 302(60.3) | 0.81 | 0.6–1.0 | 0.83 | 0.6–1.1 |
I can face the world with confidence | 625 (90.7) | 618 (93.8) | 475(95.0) | 0.64 | 0.4–1.0 | 0.54 | 0.3–1.0 |
I can travel alone by train/bus anywhere in Mumbai | 499 (72.4) | 500 (76.0) | 421(84.1) | 0.74 | 0.6–1.0 | 0.63 | 0.4–0.9 |
Response 1: I don't know; Response 2: I know.
Odds ratios adjusted for age, gender, mother's education and school.
The statistical analysis was conducted using a random effects logistic regression model adjusted for age (< = 14 yr, > = 15 yr), gender, mother's education and clustering of respondents within school.
This research was approved by the Institutional Review Board of the Healis – Sekhsaria Institute for Public Health. Standard procedures for protection of human subjects were used, and were similar to those used in collection of data for the Global Youth Tobacco Surveys. Written permission was obtained from the Education Department of the Municipal Corporation that operates all those schools; SBF facilitated entry of the survey staff in the school. Verbal informed consent from school authorities was obtained. Informed consent was not sought from parents/guardians of children; this was not feasible given schools' minimal contact with low-income parents with low literacy. Careful steps were taken to assure ethical safeguards were in place, including explaining the voluntary nature of participation in the survey; keeping the answer sheets completely anonymous, ensuring no participation from class teachers or school authorities during the administration of the survey; collecting only the relevant information concerning tobacco use and no other sensitive information of any kind; and commitment to not disclosing partial results to schools.
The 1851 respondents to the survey included 690 from the 23 8th grade control schools (total number enrolled students = 1054), 660 from the 20 8th grade intervention schools (total number enrolled students = 1045), and 501 from the 16 9th grade intervention schools (total number enrolled students = 800).
The intervention and control conditions were fairly well balanced by gender. Among 8th grade students, there were49% (n = 340) girls in the control group vs. 52% (n = 341) in the intervention group, although there were somewhat more girls in the 9th grade intervention classes (54%, n = 272). Among 8th graders, the intervention group included a somewhat larger proportion of students 14 years of age and under relative to the control group (81.5%, n = 539, compared to 73.2%, n = 503). The average age of 8th grade control group was 13.6 yrs, of 8th grade intervention group, 13.4 yrs, and of 9th grade intervention group, 14.5 yrs. We also compared the groups by mother's education as an indicator of socioeconomic status; 21% (n = 135) of mothers of 8th grade control group students received education at the 8th standard and above, compared with 28% (n = 174) of mothers in 8th grade intervention group and 37% (n = 187) of mothers in 9th grade intervention group. The differences in mothers' education between intervention and control groups were significant (p<.01); further analyses control for mother's education.
To assess awareness of SBF activities, we asked students in both conditions if they had heard of SBF; 16% of 8th graders in the control group responded “yes,” compared with 97% of 8th graders in intervention schools and 99% of 9th graders in intervention schools. We also asked respondents if they read “Halla Bol,” the SBF newsletter; 5% of 8th graders in the control group responded “yes,” compared with 50% of 8th graders in intervention schools, and 40% of 9th graders in intervention schools. The between-group differences were statistically significant (p<0.01).
As shown in
Responses to the survey indicate that students in intervention schools were significantly more likely to take key actions to prevent tobacco use in the communities and among their friends, adjusted for age, gender, school, and mother's education, as illustrated in
As noted in description of the intervention, SBF aimed to build life skills as a core strategy in tobacco use prevention. Indicators of life skills and self-efficacy were higher among students in SBF schools. As presented in
Students in SBF schools were significantly less likely to report using some form of tobacco. Among 8th grade control school students, 8.7% reported using tobacco for at least one of the last 30 days, compared to 4.1% of 8th grade intervention students (OR = .0.51, 95% CI = 0.3–0.8) and 3.6% of 9th graders in intervention schools (OR = 0.33, 95% CI = 0.2–0.6), adjusted for age, gender, school, and mother's education.
Established in 2002, the SBF program was designed to reduce tobacco use initiation among children from low socio-economic backgrounds attending government schools in Mumbai, India, following an innovative approach focused on building broad-based life skills and confidence to address life's challenges. This study used a quasi-experimental design to test the effectiveness of this program by comparing tobacco use and related knowledge and attitudes among students in SBF schools and in comparable control schools in Mumbai that have not received the SBF intervention. Specifically, we tested the hypotheses that compared to students in control schools, students in schools receiving the SBF program would be more knowledgeable about products containing tobacco and about tobacco control legislation; more likely to take action to prevent others from using tobacco; more likely to demonstrate positive life skills and attitudes; and less likely to report using tobacco in the last 30 days. Notably, these findings indicate that even after only one year of exposure to the program, students in SBF schools were only half as likely as students in control schools to have used tobacco in the last 30 days, and the proportion using tobacco after two years of exposure to the program was even further reduced. Reflecting the central premise of the SBF program, SBF students also reported stronger life skills and self-efficacy than students in control schools. In addition, compared to control school students, SBF students were significantly more knowledgeable about tobacco and related legislation, and reported significantly more efforts to prevent tobacco use among others, including with friends, in their schools and in their neighborhoods.
These findings are consistent with prior studies, including the emerging literature on tobacco use prevention efforts in India. For example, our findings about SBF students' improved knowledge about products containing tobacco and about tobacco control legislation are consistent with a study of students in New Delhi. This study found greater knowledge of tobacco, including types of tobacco and its harmful effects, was associated with lower levels of tobacco use compared to students with less knowledge of tobacco
We also found support for our hypothesis that SBF students would be more likely to take action to prevent others from using tobacco than control school students. Other studies have noted a crucial role for peer activism and engagement in successful programs designed to prevent youth tobacco use
Students in the SBF schools were more likely to demonstrate positive life skills and attitudes than students in the comparison schools. A wealth of research over the past two decades has demonstrated both short- and long-term prevention effects of life skills training on tobacco use
We are aware of only one other school-based intervention study to reduce tobacco use among adolescents in India, based in Delhi and Chennai. Investigators found overall tobacco use increased by 68% in the control group and decreased by 17% in the intervention group over 2 years
The life skills approach used in the SBF program differs in substantial ways from interventions focusing solely on tobacco education and may be particularly relevant for students from low-income communities, who often have restricted access for opportunities to build such life skills. A life skills approach is designed to enhance general personal and social competence, along with providing information and skills specific to tobacco use
Overall, these findings are consistent with prior reports. In a systematic review of school-based smoking prevention programs, Flay concluded that programs with 15 or more sessions (beginning in upper elementary/middle school and continuing to high school); were based on a social influences model; focused on changing social norms, commitments not to use and intention not to smoke; taught refusal and other life skills and engaged peers in the program delivery could reduce smoking onset by 25–50%
It is important to note several caveats in the interpretation of these results. Tobacco use was measured by self report; even though data were collected by independent evaluators with no connection to the intervention, it is possible that findings could be influenced by a social desirability bias in the intervention schools. We used a quasi-experimental design, wherein schools were not randomly assigned to condition. Although control schools were specifically selected from other government-run schools in the same general locale, we acknowledge that some unmeasured differences between the schools (e.g., location, size) and between the students (e.g., migrant status) may contribute to finding differences between SBF and comparison schools. Nonetheless, we have controlled for age, gender, and mother's education in the analyses to account for potential between-group differences. In addition, it is important to acknowledge that these results can only be generalized to similar school settings. Comparison of 9th grade intervention with 8th standard controls has a limitation of difference in the years of schooling that could not be adjusted. The age distribution was also different but that has been adjusted for. In addition, it was not possible to evaluate the potential differential effects of individual components on the intervention, or to examine the long-term effects of this intervention on tobacco use prevention.
The strengths of this evaluation include its systematic approach to surveying students from both intervention and control schools, carefully controlling for between-group differences, and assuring independence between intervention and evaluation teams. Based on prior research and on-the-ground understanding of local priorities and practices, SBF created this innovative program and had been implementing it in government schools since 2002, before requesting this independent evaluation of the program's impact. Rigorous program evaluations of existing programs, such as this one, can help highlight effective strategies from the field and facilitate their dissemination to different settings.
In India, every day more than 5,500 children under age 15 try tobacco for the first time. Currently, an estimated 5 million Indian children are addicted to tobacco
The authors deeply appreciate the cooperation of the 59 schools that participated in this study, as well as the participating students and teachers from these schools. The authors would like to thank the Salaam Bombay Foundation for arranging access to these schools, and providing information on its programs. In particular, the authors thank Padmini Somani and Devika Chaddha from SBF for obtaining government permission for entry into these schools. The authors additionally thank Namrata Puntambekar for her work on data analysis, and Linnea Benson-Whelan for contributing to manuscript production.