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 » Introduction
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  Table of Contents  
Year : 2014  |  Volume : 51  |  Issue : 5  |  Page : 19-23

Improvement in prevalence of tobacco use among teachers in Bihar after COTPA

1 Healis Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra, India
2 Dana Farber Cancer Institute, University of Minnesota, Minneapolis, India
3 Division of Epidemiology and Community Health, University of Minnesota; Harvard School of Public Health, Boston, Massachusetts, USA
4 School of Preventive Oncology, Patna, Bihar, India
5 Consulting Behavioural Scientist, New Delhi, India

Date of Web Publication19-Dec-2014

Correspondence Address:
P C Gupta
Healis Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra
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Source of Support: This work was supported by the National Cancer Institute (grants 5R01 CA120958, and 5 K05 A108663), Conflict of Interest: None

DOI: 10.4103/0019-509X.147438

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 » Abstract 

Context: A high prevalence of tobacco use, even among educated professionals like teachers, has been reported from Bihar. After passing of the Cigarette and Other Tobacco Products Act (COTPA) in 2003, there have been major improvements in tobacco control nationwide. Aims: To compare tobacco use prevalence among school teachers in Bihar reported in 2000 with a survey in 2008 and investigate correlates of current and past tobacco-use. Methods: Data from the baseline survey of a cluster random sample of 72 government schools conducted during the beginning of two consecutive school years was analyzed. Results: The prevalence of current tobacco use was 35.5% and past use, 11.3%. Likelihood of current use compared with no use increased with age (odds ratio [OR] =3.27 for > 50 years compared to < 30, 95% confidence interval [CI]: [1.50, 7.13]); whereas that of past use compared to current use decreased (OR = 0.25, 95% CI: [0.09-0.68] for age > 50 years compared to < 30 years). Discussion: Compared to the tobacco use prevalence among Bihar school teachers reported from a survey in the year 2000 (77.4%), the prevalence in this survey in 2008 was much lower and past use, much higher. In the earlier survey, lal dantmajan was counted as a tobacco product. If we do the same in the current survey, and consider ever use, the prevalence even then was 53.9%, lower than the earlier figure. Although the tobacco use among teachers in Bihar is still high, it has decreased after the implementation of COTPA and the cessation has increased.

Keywords: Cessation, demographics, legislation, teachers, tobacco-use

How to cite this article:
Gupta P C, Lando H A, Pednekar M S, Narake S S, Nagler E M, Pawar P S, Sinha D N, Aghi M B, Sorensen G S. Improvement in prevalence of tobacco use among teachers in Bihar after COTPA. Indian J Cancer 2014;51, Suppl S1:19-23

How to cite this URL:
Gupta P C, Lando H A, Pednekar M S, Narake S S, Nagler E M, Pawar P S, Sinha D N, Aghi M B, Sorensen G S. Improvement in prevalence of tobacco use among teachers in Bihar after COTPA. Indian J Cancer [serial online] 2014 [cited 2022 Dec 7];51, Suppl S1:19-23. Available from:

 » Introduction Top

The burden of tobacco-related morbidity and mortality is increasing in low- and middle-income countries. India faces particular challenges due to widespread use of multiple forms of tobacco; normative nature of tobacco use and limited availability of resources for tobacco control. [1] There were an estimated one million deaths in India in 2010 from tobacco-related causes, with increases projected in the future. [2] One of the states in India with the highest tobacco use prevalence is Bihar, a comparatively less developed state located in the North-Eastern part of the country. According to the Global Adult Tobacco Survey (GATS) conducted in 2009, the overall prevalence of tobacco use in Bihar was 54% (men, 66%). [3] This high prevalence of tobacco use appears to permeate into all strata of the society - even among medical doctors (current tobacco use-cigarette smoking: 7%; chewing or applying tobacco: 11.7%; other or mixed: 1% each). [4]

Like elsewhere in India, tobacco is used in a wide variety of forms in Bihar. In addition to cigarettes, tobacco is often smoked in the form of bidis (bidis contain a small amount [~0.25 g] of tobacco flakes rolled in a dry tendu leaf [Diospyrous melanoxylin], into a conical shape tied with thread). Tobacco is also used in multiple smokeless forms, the most common being a mixture of tobacco and slaked lime called khaini. Another common form of using smokeless tobacco (SLT) in Bihar is pan or betel-quid with tobacco. It is made by smearing slaked lime (calcium hydroxide) paste on a fresh betel leaf and adding pieces of areca nut, tobacco flakes and other condiments as per preference. A special mention must be made of lal dantmanjan or red toothpowder. This is a dentifrice that is very commonly used in Bihar. Until 10-15 years ago, prominent companies manufacturing the red toothpowder listed tobacco as an ingredient. After a court case in 1997, it was finally ruled that tobacco cannot be used as an ingredient in a dentifrice. Since then, companies claim that they do not add tobacco to red toothpowder. Including this toothpowder as a tobacco product can substantially change estimates of tobacco use prevalence in Bihar. [5],[6] Laboratory analyses however, still show high nicotine content in several dentifrice products, [7] thus highlighting the importance of considering this product separately when measuring tobacco use.

Tobacco use cessation is the major vehicle for substantially reducing the tobacco death toll in the relatively near term. However, encouraging cessation is especially challenging in a context where there are few tobacco cessation resources, where even highly educated professionals use tobacco, and where there are limited numbers of former users as role models. [3]

Teachers are a highly respected occupational group in Bihar. Therefore, there is an opportunity for teachers to be important role models, both for abstaining from tobacco themselves and in encouraging others to quit. [8] Unfortunately, however, tobacco use was reported to be particularly high among school personnel in Bihar in Global School Personnel Survey (GSPS). [9] In a representative sample of 50 schools from 9905 state government schools in Bihar in September-October 2000, the prevalence of tobacco use among school personnel was 77.4% with almost identical proportions of men and women reporting current use (77.6% and 77%, respectively). [9] It was also reported that there were almost no tobacco control policies observed in those schools at that time. Around the same time, another survey using identical methods was conducted in a representative sample of 50 out of 103 federal schools of Bihar State. [10] Although located within Bihar State, these schools are directly administered by an agency of the federal government and they follow specified curriculum and policies of the federal government. The findings on tobacco use prevalence among personnel in these schools were compared with state schools. In Federal schools, only 2.4% of school personnel reported current daily cigarette smoking compared to 14.5% in state government schools and 14.1% reported daily SLT use compared to 41.7% in state government schools. A major difference was that between a half to two-third of respondents in Federal schools reported that tobacco control policies were observed and enforced in their schools as opposed to virtually none (<0.5%) in the state government schools. [10]

Since those surveys, there have been major improvements in tobacco control nationwide, affecting every state including Bihar. India ratified the Framework Convention on Tobacco Control (FCTC, the first international treaty relating to public health) in 2003 and passed comprehensive tobacco control legislation, the Cigarette and Other Tobacco Products Act (COTPA). This legislation, popularly known as COTPA, banned smoking in enclosed public places, including educational institutions and work places, and prohibited tobacco sales within 100 yards of any school. Although enforcement of the law is far from being perfect, these regulations have generated a huge amount of media coverage and appear likely to have affected tobacco use prevalence and quit rates in the population. [11],[12]

An analysis of the baseline survey of the Bihar school teachers study (BSTS) is reported here to assess the possible impact of national tobacco control legislation on school personnel tobacco use, as well as correlates of current versus past use of tobacco.

 » Methods Top

The BSTS was a cluster randomized trial testing an intervention (The Tobacco-Free Teachers/Tobacco-Free Society program) aimed at decreasing teachers' tobacco use and increasing the adoption, implementation, and enforcement of school tobacco control policies. Specifics of the intervention program and selection of participating schools has been described previously. [13],[14] Briefly, we randomly selected 72 government schools with grades 8-10 from 10 school districts in Bihar. Eligible schools had at least 8 teachers. We excluded school districts located in flood zones because school closures would preclude intervention delivery. Baseline surveys, the data from which we report here, were scheduled during the beginning of the school year (June-July) and were conducted in 2 waves over 2 consecutive years: Wave 1 in 2009 and wave 2 in 2010. All 72 schools participated in the baseline survey: 36 in wave 1 and 36 in wave 2.

Relevant characteristics were collected for 66 of the 72 participating schools. The average distance from the study office located in the capital, Patna, was 99 km (maximum 400 km; minimum 6 km). Only 41% of the schools had electricity and 78% of them were located in the urban areas.

A 55-question survey instrument was developed using questions mainly from the GSPS and it was pretested. The questions to assess tobacco use were: Do you currently use any smokeless tobacco product; and Have you quit using smokeless tobacco; Do you currently smoke tobacco in any form; and have you quit smoking; type of tobacco product consumed (pan [betel-quid]; gutka or pan masala or tobacco lime areca nut mixture; khaini or tobacco lime mixture; gul, gudakhu, dentoback [creamy snuff]; lal dantamanjan; other forms; for SLT products; and cigarette; bidi; hukka [water pipe]; bidi and cigarettes; other forms of tobacco for smoking products). The self-administered questionnaire was in Hindi, the language of Bihar. All school personnel who were present at the school on the day of the survey were invited to participate.

The units of analyses were individuals participating in the survey. Descriptive analyses were completed for all respondents. Because of the government mandatory retirement policy, almost all (>99%) respondents were ≤ 60 years old. Logistic regression was used for multivariate analyses to associate demographic correlates with prevalence of current tobacco use compared to no tobacco use and past tobacco use compared to current tobacco use. Odds ratios (OR) obtained were adjusted for age, gender, school, and type of school (urban, rural). SPSS version 20.0 was used to conduct data analysis.

The study was approved by the Indian Council of Medical Research and ethical clearances were obtained from the Institutional Review Boards in India and USA. Prior approval for conducting this study was obtained from the Department of Education, Government of Bihar that administers these schools.

 » Results Top

The response rate for schools was 100% and for school personnel, 80%. The most common reason for non response was absence on the day of the survey. There were no refusals. A total of 756 school personnel participated in the survey, including 499 males and 257 females. One male respondent did not answer questions pertaining to tobacco use and that respondent was excluded from analyses. The results therefore are based on 755 respondents. Among these 65 were principals and 648 were teachers (total 94.4%) and the rest were office staff.

[Table 1] shows tobacco use status by sociodemographic factors. Current as well as past use was higher among men than among women (48.0% and 13.5% vs. 11.3 and 7.0%). Current tobacco use increased with age from 20.7% among those <30 years of age to 41.9% among those >50 years of age. In contrast, past use decreased with age from 15.5% in those <30 years old to 9.0% among those >50 years current use was higher in rural (40.3%) compared to urban areas (32.0%).
Table 1: Distribution of socioeconomic and demographic characteristics by self - reported tobacco use status for BSTS baseline survey in Bihar state

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Women in India generally do not smoke due to social unacceptability. Therefore although overall tobacco use was higher among males than females, the difference was considerably more pronounced for smoking (13 times greater for males) than for SLT (3 times higher), as shown in [Table 2]. Interestingly, among 148 males who were ever smokers, almost two-third (n = 96, 64.9%) had quit. However, among 283 males who were ever SLT users, only 52 (18.4%) had quit. Among female SLT users, 37% had quit (17 former out of 46 ever users).
Table 2: Status of tobacco use by pattern and gender

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[Table 3] shows the type of tobacco products used by this population. Among smokers, cigarettes were the most common. Among SLT users, khaini was the most common, followed by betel quid (pan) with tobacco.
Table 3: Type of tobacco product used

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Logistic regression modeling that included age, gender, education, designation, marital status and type of school (urban, rural) is shown in [Table 4]. Looking at the age distribution, it is clear that school personnel aged over 50 were the most likely to be current users (OR = 3.27, 95% confidence interval [CI]: [1.50, 7.13]; reference group never users <30) with a clear age gradient. In contrast, comparing past users with current users, older persons were much less likely to be past users than younger ones (OR = 0.25, 95% CI: [0.09-0.68] for age >50 years compared to age <30 years) again with a clear age gradient. Males were much more likely than females to be current users (OR = 10.9, 95% CI: {6.80-17.58}) but less likely to be past users (OR = 0.41, 95% CI: [0.20-0.81]). Although almost all respondents were well-educated (623 out of 755 had college education or higher), those with more education were less likely to be current users (OR = 1.85, 95% CI: 1.05-3.29 for below college compared to above college) and more likely to be former users compared with current users (OR = 0.41, 95% 0.17-0.99; below college vs. above college).
Table 4: Adjusted OR, 95% CI for the association between demographic characteristics and tobacco use in BSTS baseline survey

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 » Discussion Top

Results from this survey show that while rates of tobacco use among teachers in Bihar (35.5%) are still high, they have substantially decreased compared with earlier reports. In the GSPS conducted in 2000, the prevalence of tobacco use among school teachers was reported to be a staggering 77.4%. [15] The prevalence is also lower than rates of tobacco use in Bihar, as reported in the GATS survey (53.5%). [3]

It should be noted that in the survey of year 2000 (GSPS), lal dantmanjan was counted as a tobacco product; in the current study use of lal dantmanjan was considered separately. A strong association between tobacco use and use of lal dantmanjan can be discerned from [Table 1]. The use of lal dantmanjan was reported by 82 current tobacco users, whereas no lal dantmanjan use was reported by 186 current tobacco users giving percentage of lal dantmanjan users among current tobacco users as 30.6%. Similarly, percentage of lal dantmanjan users can be computed among former users as 20.2%, (17/[17 + 67]) and among nonusers as 13.4%, (54/[54 + 348]). These numbers reveal a strong association between lal dantmanjan use and tobacco use (OR for the current use of both vs. none 2.8, 95% CI: 1.93-4.18). Thus if we include all lal dantmanjan users as tobacco users, then there would be additional 54 persons, who can be counted as tobacco-users since they reported using lal dantmanjan [Table 1]. Therefore, inclusion of lal dantmanjan as tobacco a product would increase tobacco use prevalence by 7.1% (54/755). Thus, after including lal dantmanjan, as tobacco product, the ever tobacco use in the current study was 53.9% (35.5 + 11.3 + 7.1). This still represents a considerable decrease in tobacco use prevalence from 77.4% in 2000. [15] As stated earlier; this period coincides with major changes in the tobacco control policies in the country, which may have contributed significantly to reduction of tobacco prevalence.

The prevalence of past use (11.3%) in the current survey is also encouraging. In the GSPS in September-October 2000, former tobacco use in school teachers of Bihar was rare (1.8%). [15] Thus, there appears to have been a substantial increase in quitting. In the GATS of the general population, past use in Bihar among those aged 15 years and above was 7.2%. [3] The current study data for school personnel indicated increases in past use with both decreasing age and increasing education level. If the same is true for general population, a higher proportion of former tobacco users among school personnel might be expected.

There are several strengths of the study. The sample was a probability sample of schools from a large part of Bihar, so the data are reasonably representative. The information was collected through self-administered questionnaire without name or address of the respondent so presumably there should have been less hesitation in responding to even somewhat less comfortable questions. The major limitation of the study was that tobacco use was self-reported with no biochemical verification.

Although the reduction in tobacco use prevalence among teachers in Bihar is encouraging, overall rates of use, especially of SLT among men, continue to be of concern. Teachers are important role models. Their continuing use of tobacco sets a bad example for others, including the next generation of youth. Progress is being made with the advancement of tobacco control policies in accordance with the FCTC. However, further efforts are needed both in reducing tobacco use among teachers and in the general population. Continued implementation of effective tobacco control policies along with providing tobacco cessation interventions and support can make a difference in further reducing tobacco use prevalence. It is our hope that teachers can lead the way as nonsmoking role models and that their use of all forms of tobacco will become decreasingly common.

 » Acknowledgment Top

The authors would like to thank the numerous investigators and staff members in India and the United States who contributed to this study, including Quayyim Ansari, Lauren Becker, Linnea Benson-Whelan, Ellen Connorton, Caitlin Eicher Caspi, Joshua Gagne, Adam Gerberick, Christopher Kenwood, Neha Mathur, Amruta Miland, Shree Mukesh, Claudia R. Pischke, Divya Ramamurthi, David Rothfarb, Laura Shulman, Melanie Silverman, Gupteshwar Singh, Manibala Singh, Namrata Puntambekar and Lorraine Wallace.

In addition, this work could not have been completed without the participation of the 72 government schools in Bihar and the Health Educators and staff at the School of Preventive Oncology in Patna, Bihar. Finally, the authors also thank the Education Department of the Bihar State Government for its support of this study.


The author alone is responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

 » References Top

Reddy KS, Gupta PC. Report on Tobacco Control in India. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2004.  Back to cited text no. 1
Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med 2008;358:1137-47.  Back to cited text no. 2
International Institute for Population Sciences. Global Adult Tobacco Survey (GATS) India 2009-2010. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2010.  Back to cited text no. 3
Sinha DN, Gupta PC. Tobacco use among medical doctors in Bihar: Results from the Global Medical Doctors Survey. Indian J Public Health 2004;3:144-6.  Back to cited text no. 4
Sinha DN, Gupta PC, Pednekar MS. Use of tobacco products as dentifrice among adolescents in India: Questionnaire study. BMJ 2004;328:323-4.  Back to cited text no. 5
Sinha DN, Gupta PC, Pednekar MS. Tobacco use in rural area of Bihar, India. Indian J Community Med 2003;28:167-70.  Back to cited text no. 6
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Sinha DN, Gupta PC, Pednekar MS, Jones JT, Warren CW. Tobacco use among school personnel in Bihar, India. Tob Control 2002;11:82-3.  Back to cited text no. 9
Sinha DN, Gupta PC, Warren CW, Asma S. Effect of school policy on tobacco use by school personnel in Bihar, India. J Sch Health 2004;74:3-5.  Back to cited text no. 10
Raute LJ, Sansone G, Pednekar MS, Fong GT, Gupta PC, Quah AC, et al. Knowledge of health effects and intentions to quit among smokeless tobacco users in India: Findings from the International Tobacco Control Policy Evaluation (ITC) India Pilot Survey. Asian Pac J Cancer Prev 2011;12:1233-8.  Back to cited text no. 11
Sansone GC, Raute LJ, Fong GT, Pednekar MS, Quah AC, Bansal-Travers M, et al. Knowledge of health effects and intentions to quit among smokers in India: Findings from the Tobacco Control Policy (TCP) India pilot survey. Int J Environ Res Public Health 2012;9:564-78.  Back to cited text no. 12
Nagler EM, Pednekar MS, Viswanath K, Sinha DN, Aghi MB, Pischke CR, et al. Designing in the social context: Using the social contextual model of health behavior change to develop a tobacco control intervention for teachers in India. Health Educ Res 2013;28:113-29.  Back to cited text no. 13
Sorensen G, Pednekar MS, Sinha DN, Stoddard AM, Nagler E, Aghi MB, et al. Effects of a tobacco control intervention for teachers in India: Results of the Bihar school teachers study. Am J Public Health 2013;103:2035-40.  Back to cited text no. 14
Sorensen G, Gupta PC, Sinha DN, Shastri S, Kamat M, Pednekar MS, et al. Teacher tobacco use and tobacco use prevention in two regions in India: Results of the global school personnel survey. Prev Med 2005;41:417-23.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4]


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