|Year : 2022 | Volume
| Issue : 3 | Page : 392-399
Burden and determinants of substance abuse among urban adolescents of Shimla city: How vulnerable are our future citizens
Rakesh Thakur, Dineshwar S Dhadwal, Tripti Chauhan, Vijay Kumar Barwal
Department of Community Medicine, Indira Gandhi Medical College, Himachal Pradesh, India
|Date of Submission||21-Apr-2022|
|Date of Acceptance||01-Sep-2022|
|Date of Web Publication||29-Sep-2022|
Dr. Vijay Kumar Barwal
Department of Community Medicine, Indira Gandhi Medical College, Himachal Pradesh 171001
Source of Support: None, Conflict of Interest: None
Background: Substance abuse is a major but neglected public health problem across the globe. Most of the time it starts during adolescence, which is also considered a critical risk period for the initiation of substance use. Materials and Methods: We conducted a cross-sectional analytical study to estimate the prevalence and determine the association of socio-demographic and other risk factors with substance abuse among adolescents in an urban area of Himachal Pradesh. A multi-stage cluster with probability proportional to size sampling technique was followed and a semi-structured, pretested questionnaire was used as the study tool. Results: We studied a total of 728 participants and 39.6% were females. The mean age was 15.6 ± 1.3 years. Out of these, 12.1% reported any substance abuse earlier in their lifetime. Among ever users, most commonly abused substance was alcohol (8.9%), followed by smoked tobacco (7.1%), bhang (3.7%), hard liquor (2.8%), charas/ganja (1.4%), chewing tobacco (1.4%), inhalants (fluid/eraser) 0.82%, prescription drugs (cough syrup/tablets 0.69% and injecting drugs 0.27%), Chitta (0.27%), opium and heroin with 0.14% each. On multiple logistic regression analysis, male gender (AOR=1.82), among friend’s tobacco smoking (AOR=2.33), alcohol abuse (AOR=4.52), and cannabis abuse (AOR=2.99) were found to be associated with an increased likelihood of substance abuse. High socio-economic status (AOR=0.59) and tobacco chewing among friends (AOR=0.49) had a protective effect on indulgence in substance abuse. Conclusion: The influence of peers played the most significant predictor while the presence of substance abuse in the family was also associated with an increased likelihood of abuse by adolescents.
Keywords: Adolescents, determinants, prevalence, substance abuse
|How to cite this article:|
Thakur R, Dhadwal DS, Chauhan T, Barwal VK. Burden and determinants of substance abuse among urban adolescents of Shimla city: How vulnerable are our future citizens. MGM J Med Sci 2022;9:392-9
|How to cite this URL:|
Thakur R, Dhadwal DS, Chauhan T, Barwal VK. Burden and determinants of substance abuse among urban adolescents of Shimla city: How vulnerable are our future citizens. MGM J Med Sci [serial online] 2022 [cited 2023 Feb 6];9:392-9. Available from: http://www.mgmjms.com/text.asp?2022/9/3/392/357472
| Introduction|| |
Substance abuse is the harmful or hazardous use of psychoactive substances, including alcohol and illicit drugs. It is a major but neglected public health problem across the globe. Children and adolescents face pressure to use alcohol, cigarettes, or other drugs, putting themselves at high risk for intentional and unintentional injuries. Many also experience a wide range of adjustment and mental health problems.
There may be a lack of appropriate care, love, and nurturing, a low level of family income and education, separated, homeless children, child of divorced parents with no structure at home, which compels them towards substance abuse.The influence of substance-abusing peers, academic failures, and poor social skills puts them at even more risk.
Due to the high prevalence of substance abuse, Punjab, a neighboring state of Himachal Pradesh, has got the title of “Udta Punjab”. After Punjab and Chandigarh, Himachal Pradesh ranks third in NDPS cases registered for possession of drugs for trafficking. Research on substance abuse provides an essential source of information about the extent and pattern of substance use and its socio-demographic correlates. Hence, we conducted this study to estimate the prevalence and predictors of substance abuse among school-going adolescents in Shimla city of Himachal Pradesh. It would help policymakers, program managers, and planners to devise public health interventions accordingly and the data will also aid the law enforcement agencies to combat this menace.
| Materials and methods|| |
This cross-sectional analytical study was conducted from 1st October 2020 through March 2021, among school-going adolescents of classes 8th to 12th studying in various senior secondary schools under the limits of the municipal corporation of Shimla city. All adolescents aged 13–19 years were included in the study.
Sample size and sampling
The desired sample size using the formula: Sample size (n)= (1.96)2 pq\ L2. We do not have data on the prevalence of substance abuse in the study area. However similar studies conducted elsewhere,,,, in the country have yielded a range from 11.8% to 60%. Therefore, assuming prevalence to be 25%, considering normal deviate (Z) =1.96 at a 0.05 level of significance, the allowable absolute error of 5% and confidence level of 95%, non-compliance rate of 20%, and taking a design effect of 2.0, the sample size worked out to be 720.
A multi-stage cluster sampling technique was followed to draw a representative sample of the study population [Figure 1]. In the first stage, we procured a list of the total of 39 Senior secondary schools in Shimla city along with the class-wise strength of students. We then stratified them into 26 Private and 13 Government owned schools (Primary sampling units). Then using the probability-proportionate-to-size technique, we selected 8 Private and 4 Government schools. In the next stage, two classes from each school were selected by simple random sampling (SRS) technique (Secondary sampling units). In the last stage, we selected a minimum of 60 students from the two selected classes (Elementary sampling units) of the respective schools. In case the two selected classes had more than 60 students, we administered the questionnaire to all the students, and then later 60 forms were selected randomly. If the strength was less than 60, then the next higher class (or lower in case class 12 was already chosen) was taken up similarly as above and we selected 60 students. (Selected classes in two schools had 63 students, while one had 62 students so we include all of them in the sample). The rest of the selected classes had a total of students well above 70, so we randomly selected 60 each from these classes. Hence the final sample studied was 728.
A pre-tested self-administered anonymous, structured questionnaire was used to assess the prevalence and risk factors of substance abuse in schools. A Modified Kuppuswamy scale, updated for the year 2020, was used to assess the socio-economic status of the study participants. The questionnaire as well as the operational definitions of the variables was adopted from the WHO model core questionnaire self-administered format and was modified as per the local needs.
Is any psychoactive substance or drug licit or illicit that, when absorbed in the body of living organisms, alters normal bodily, cognitive, and mental functions.
It is the non-medical use of drugs/substances that destroys the health and productive life of an individual.
Who has consumed any form of the substance at any time in life but it does not include small experimental quantities like a few sips of alcohol or a few puffs of smoking tobacco etc.
Who is consuming any of the substance less than thrice per week but has taken it off and on for the past year?
Someone who is consuming any of the substances three or more times per week in the past month.
Data were analyzed using Epi info version 22.214.171.124 software. Descriptive statistics and frequency percentages were determined for categorical variables. Means and standard deviations were calculated for quantitative variables. Qualitative variables were analyzed using the chi-square test. All those variables with a P-value of ≤ 0.1 on univariate analysis were included for multivariate analysis. Multiple logistic Regression analysis was employed to find the association of various risk factors with substance abuse. A p-value of <0.05 was considered statistically significant.
Ethical issues and participants consent
The study was carried out after taking due permission from the institutional ethics committee. In the case of government schools, permission to conduct the survey was sought from the Director of education, while the permission of Principals of the selected private schools was taken after explaining to them the purpose of the study. Written informed consent was obtained from parents/guardians along with the assent of every participating student. It was done well in advance by sending the forms through the principal of the school, then to the class teachers, and further to the parents via their wards. The signed consent forms were collected back by the class teachers and handed over to the investigator. After obtaining consent and assent, the questionnaire was administered to all the students of the selected classes. To maintain confidentiality, privacy, and anonymity, they were made to sit in separate rooms. Also, to minimize response bias their regular teachers were requested to be away from the class while the students marked their responses.
The forms were distributed to only those students who were selected randomly as per the sampling procedure explained in [Figure 1]. Students answered all the questions. Those who could not understand the questions or had any doubts were explained there and then by the investigator as he remained there while they were filling in the responses.
| Results|| |
We studied 728 participants with 459 males and the mean age was 15.6 ± 1.3yrs. All the participants belonged to urban areas and 61.4% were studying in private schools. Nearly two third of the participants belonged to nuclear families (60.9%) and the majority of them were staying with their parents (83.8%) but only a few students (19.6%) were able to spend quality time with them. As far as the educational status of parents is concerned, 52.8% of fathers and 45% of mothers of the participants were highly educated (graduate and above). According to Modified Kuppuswami Scale, most of the participants belonged to the Upper (57.9%) and upper-middle classes (26.1%) [Table 1].
|Table 1: Distribution of study subjects according to the socio-demographic profile of their families|
Click here to view
Overall prevalence of substance abuse was 12.09% [95% Confidence interval (CI):9.9 -14.7]. 13.73% (95%CI: 10.9 -17.2) males had ever used different substances compared to females where ever users were 9.29% (95% CI: 6.1 -13.4) [Figure 2].
|Figure 2: Overall prevalence of substance abuse according to their gender|
Click here to view
Among ever users [Table 2], most commonly abused substance was alcohol (beer/wine) 8.93% followed by smoked tobacco (7.14%), bhang (ghota, pakora) 3.71%, hard liquor (2.75%), charas/ganja (1.37%), chewing (pan/gutka)1.37% and inhalants (fluid/eraser) 0.82%.
|Table 2: Distribution of study subjects according to type and frequency of substance abuse|
Click here to view
Regular substance abuse [Table 2] was reported at 3.57% for tobacco smoking followed by 2.34% alcohol(beer/wine), 0.96% chewed (pan/gutka), 0.55% used bhang (ghota/pakora), inhalants by 0.41%, charas and oral prescription drugs by 0.27%, and lastly hard liquor and chitta at 0.14% each. There were no regular abusers of opium, heroin, or injecting drugs.
Occasional use [Table 2] of alcohol (beer/wine) stood at 6.59%, followed by tobacco smoking (3.57%), bhang (3.16%), hard liquor (2.61%), charas/ganja (1.1%), chewing pan/gutka, inhalants, and oral prescription drugs by 0.41% each, injecting drugs by 0.27% and remaining opium, heroin, and chitta by 0.14% each.
Nearly 44.8% of the participants reported that one of their family members indulged in substance abuse while friends of more than half of the students (54.5%) were consuming such substances. On univariate analysis [Table 3], male gender [Unadjusted odds ratio (UOR)=1.55], and among friends’ tobacco smoking (UOR=7.19) and chewing (UOR=1.96), alcohol and cannabis consumption (UOR=8.99 and 5.12), other drugs abuse (UOR =1.85) and smoking at home (UOR=1.79) were found to be significantly associated with substance abuse. All the variables with a P< 0.1 were further taken up for multiple logistic regression [Table 3]. Here male gender (Adjusted odds ratio [AOR]=1.82, P=0.02), tobacco smoking among friends (AOR=2.33, P=0.03), alcohol abuse (AOR=4.52, P=0.00), and cannabis abuse (AOR=2.99, P=0.00) were found to be significantly associated with increased likelihood of substance abuse. High socio-economic status (AOR=0.59, P=0.03) and tobacco chewing among friends (AOR=0.49, P=0.01) had a preventive effect against indulgence in substance abuse.
|Table 3: Association of risk factors on Multiple Logistic Regression with unadjusted (UOR) and adjusted (AOR) odds ratios|
Click here to view
| Discussion|| |
Globally there is a widespread prevalence of substance abuse among adolescents as reported by various studies. Over ten years from 2009–2018, the estimated number of past-year users of any drug increased from 210 million to 269 million i.e. by more than a quarter (28%). Consequently, the prevalence of drug use increased by over 12%, from 4.8% of the adult population in 2009 to 5.4% in 2018. The pattern of consumption of different substances showed that 192 million people consumed cannabis, 58 million opioids, 27 million used amphetamines and prescription stimulants, 21 million ecstasies, and 19 million used cocaine.
In the past few years, a drastic change is seen in substance abuse types with an increasing trend among women. In Himachal Pradesh (HP), as per the report of the national family health survey 2019–20, there is an increasing trend of smoking and alcohol use among women compared to men. Our study also corroborates this with a prevalence of 9.29% in female adolescents. When it comes to the possession of drugs for trafficking in India, Himachal has the third-highest crime rate of 12.8 cases registered per lakh population, after Punjab (19.3) and Chandigarh (15.2). Substance abuse is dependent on multiple factors that have been explored in different regions of the world but it requires more attention in developing countries like India. The present study has brought out certain important aspects of this problem which continues to constitute a serious threat to public health and the safety and well-being of humanity-particularly children, young people, and their families.
We found that the overall prevalence of substance abuse was 12.09% [Figure 2]. Similarly, a study done by Dasgupta A et al in West Bengal showed an overall prevalence of 12.5% among adolescents. However, a much higher prevalence at 27.4% was observed by Thakur et al among school-going adolescents in the Kullu district of Himachal Pradesh (HP).
In the present study overall smoking tobacco prevalence was found to be 7.14% [Table 2]. This was in concordance with Kapil et al who found that 7.1% of the study students were currently smoking tobacco in Delhi however NFHS-4 survey 2016–17 for Himachal reported a 9.1% prevalence and Thakur D et al reported an overall prevalence of 11.8% on Cigarette smoking behavior among adolescents in Shimla city.
In our study Alcohol (beer/wine) was the most commonly ever used substance with 8.93% of users. Nearly 6.59% of participants had tried it occasionally while only 2.34% were regular users. Similarly, every user for hard liquor were only 2.75% and occasional and regular user were 2.6% and 0.14% respectively [Table 2]. Low regular usage may be due to a lack of money or opportunities as most of the participants lived with their parents. The mean age of initiation of alcohol (beer/wine) use was 14.8 ± 1.51 years. This is similar to the mean age observed by Saxena et al and Qadri et al. In the present study Alcohol (beer/wine) was the most prevalent form of abuse which is because alcohol is a socially acceptable drink with free usage in festivals and marriages. Shimla is a tourist place people from various countries visit here for revelry resulting in a significant influence on the impressionable age of adolescents. In concordance with our study, the National Family Health Survey (NFHS-4) reported a prevalence of 8.5% of alcohol use among 15 -19 years adolescents. Contrary to our study, a higher prevalence was reported by Ningoham et al in Imphal (29%) and Qadri et al in Haryana (44.5%). Low usage rates were observed by Baba et al in Kashmir (6.2%) which primarily may be due to religious forbiddance there.
Cannabis (bhang) was the most common illicit substance used by the participants with an overall prevalence of 3.7% [Table 2]. This was followed by the use of Charas at 1.37%, inhalants at 0.82%, Prescription drugs (0.69%), and other hard drugs like opium, chitta, etc. at 0.14%, and 0.27% respectively. Himachal Pradesh is especially known for cannabis cultivation with many local people involved in its production in the lure of easy money. Shimla being the state capital is a hub for illicit cannabis trafficking. The keen involvement of foreign tourists adds to the incentive. These changing social values and relative ease of availability have probably led to increased use in adolescents. Contrary to our findings, very few studies have reported a higher prevalence than Ningoham et al in Manipur and Thakur et al. reported a higher prevalence at 6.3% in adolescents of Kullu, Himachal. It may be due to socio-cultural acceptance where even children are also working in illegal fields helping their parents. For other illicit drugs, Qadri et al reported nearly 6.5% opium users while inhalant usage was 2.6%. On the other hand, Saxena et al reported 0.4% for hard drugs like opium and 0.4% for solvents while Thakur et al reported the use of inhalants, shoe polish, etc at 3.6% and other prescription and hard drugs like cocaine, opium, etc. at 1.2% and 1.1% respectively. This wide range of variation in usage rate may be attributed partly to the absence of a uniform methodology, and target population and also to varied socio-cultural settings in different parts of India.
In our study, age was a significant predictor of substance abuse. The late adolescent age group was found to be more frequent substance abusers (UOR=1.45, 95% CI: 0.89–2.34). With increasing age, adolescents’ sphere of influence and experimental mentality increases while the control of parents weakens, thus culminating in increased usage in higher age groups.
A significant association was found between gender and the prevalence of substance abuse. Males had a higher odds (AOR=1.82,95%CI:1.07–3.09) of being substance abusers [Table 3]. Similar results were observed by many others, especially in India.,,,, It may be due to relatively more parental tolerance of the drinking behavior of their male children. In our society still there is gender bias, therefore males have lesser societal constraints and are thus more experimental in their outlook. The prevalence rates in the western hemisphere however varied by sex. A Canadian survey and another study in the USA, found that substance abuse was equally prevalent in both sexes.
In our study, higher socioeconomic status was a protective factor for substance abuse (AOR=0.59,95%CI:0.36–0.96) and was also statistically significant [Table 3]. This is contrary to the fact that students with higher economic status may receive a higher amount of pocket money but here other factors like availability, openness, awareness in the society, etc may have played a role that needs to be studied separately.
Students with friends consuming alcohol had higher odds of alcohol intake (AOR=4.52,95%CI:2.12–9.68). These findings are consistent with the results of other studies.,, It has been seen that family members and peers have a strong influence on the young minds of adolescents. Our study also found that those adolescents whose friends used to smoke tobacco were found to have indulged in its abuse with higher odds (AOR=2.33,95%CI:1.08–5.02). Similarly, smoking inside homes by family members and others had higher odds of students also indulging in smoking (AOR=1.59,95%CI:0.94–2.67). These findings are similar to studies done elsewhere.,, We also observed that cannabis abuse among friends was associated with higher odds of substance abuse (AOR=2.99,(5%CI:1.66–5.43). It is similar to observations by Taran SJ et al. Surprisingly, we found that tobacco chewing among friends acted as a protective factor (AOR=0.49,95%CI:0.27–0.88). This is contrary to the findings by Bagchi NN et al. Chewing pan/gutka and abusing other drugs gives a bad impression and it is also socially unacceptable here. This might be the reason for the low prevalence among students with friends consuming pan/gutka and other drugs.
This study has been conducted among students in the urban area of one city only, so the generalization to other cities has to be cautiously done. Though many students studying in these schools come from nearby rural areas still there may be limited generalizability to rural areas. A larger sample size taking the whole state as the sampling frame may give better external validity. The self-reported questionnaires like the one used here are known to have less reliability for assessment, so the possibility of under-reporting cannot be ruled out.
| Conclusion|| |
The study highlights that adolescents are more likely to indulge in substance abuse with increasing age so the efforts to control the problem should be directed towards adolescents at an early age. The influence of peers played the most significant predictor of substance abuse in this study. The parents should strictly monitor the friends and company of their children. Constant interaction and spending quality time with them will inculcate healthy habits and lifestyles in them. This will also empower them to resist peer pressure.
All schools should work towards the capacity building, and training of all staff members to prevent and control substance abuse and they should appoint a nodal officer specifically dealing with the issue. Substance abuse in schools should be managed under strict standard protocol. A trained psychologist/counselor should be available at every school to bring about behavior change in the early stages of adolescence. The role of peer educators should be reinforced to encourage students to counsel and help-seeking while maintaining privacy and confidentiality.
Approval/Clearance has been obtained from the Institutional Ethics Committee of Indira Gandhi Medical College Shimla to undertake the proposed research project on “Burden and Determinants of Substance Abuse Among Urban Adolescents of Shimla City: How Vulnerable are our Future Citizens” vide their letter no. 53/2020 dated 21-09-2020.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
World Health Organization. Adolescent and young adult health. Geneva: WHO; 2021. Available from https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions
[Last accessed on 20 Apr 2022].
United Nations Office on Drugs and Crime (UNODC). World Drug Report 2020 (United Nations publication, Sales No. E.20.XI.6). Vienna, Austria: United Nations Office on Drugs and Crime 2021. p. 82. Available from https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html
[Last accessed on 30 Mar 2022].
Frequently asked questions. National Institute on Drug abuse. Advancing addiction science. Available from: https://nida.nih.gov/about-nida/frequently-asked-questions
[Last accessed on 12 Aug 2022].
ET Bureau. Mumbai. Udta Punjab row: High court says it’s fed up with CBFC’s working; to deliver the order on Monday. The Economic Times [Internet]. 11 Jun 2016. 02:52 AM IST. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/articleshow/52696752.cms?from=md, June 11, 2016
. [Last accessed on 12 Mar 2022].
Crime in India 2018- Statistics, Volume 1. National Crime Bureau. Ministry of Home affairs. Government of India. National Highway–8, Mahipalpur, New Delhi. Available from: https://ncrb.gov.in/sites/default/files/Crime%20in%20India%202018%20-%20Volume%201.pdf
[Last accessed on 10 Apr 2022].
Tsering D, Pal R, Dasgupta A Substance use among adolescent high school students in India: A survey of knowledge, attitude, and opinion. J Pharm Bioallied Sci 2010;2:137-40.
Thakur S, Singh H, Sachdeva A, Barwal V Prevalence and correlates of alcohol abuse among school going adolescents in a hilly district of Himalayan region in India. J Adv Med Dent Scie Res 2017;5: 5-10.
Kapil U, Goindi G, Singh V, Kaur S, Singh P Consumption of tobacco, alcohol and betel leaf amongst school children in delhi. Indian J Pediatr 2005;72:993.
Thakur D, Gupta A, Thakur A, Mazta SR, Sharma D Prevalence of cigarette smoking and its predictors among school going adolescents of north india. South Asian J Cancer 2014;3:193-5.
Qadri SS, Goel RKD, Singh J, Ahluwalia SK, Pathak R, Bashir H, et al
. Prevalence and pattern of substance abuse among school children in northern India: A rapid assessment study. Int J Med Sci Public Health 2013;2:273-282.
Guide to drug abuse: Epidemiology. Department of Mental health and Substance Dependence. Noncommunicable diseases and Mental health Cluster, World Health Organization, 2000. Available from: https://apps.who.int/iris/bitstream/handle/10665/63850/a58352_PartA.pdf?sequence=1&isAllowed=y
[Last accessed on 10 Apr 2022].
Saxena V, Saxena Y, Kishore G, Kumar P A study on substance abuse among school going male adolescents of doiwala block, district dehradun. Indian J Public Health 2010;54:197-200.
National Family Health Survey (NFHS-4), 2015–16. International Institute for Population Sciences (IIPS), Deonar, Mumbai. India. December 2017. Available from http://rchiips.org/nfhs/nfhs-4Reports/India.pdf
. [Last accessed on 15 Mar 2022]
Ningombam S, Hutin Y, Murhekar MV Prevalence and pattern of substance use among the higher secondary school students of Imphal, Manipur, India. Natl Med J India 2011;24:11-5.
Baba TA, Ganai AM, Qadri SS, Margoob MA, Iqbal QM, Khan ZA An Epidemiological study on Substance Abuse among college students of north India Kashmir valley. Int J Med Sci Public Health 2013;2: 562-567.
Sarangi L, Acharya HP, Panigrahi OP Substance abuse among adolescents in urban slums of sambalpur. Indian J Community Med 2008;33:265-7.
National Center on Addiction and Substance Abuse at Columbia University. National Survey of American Attitudes on Substance Abuse XVI: Teens and Parents, August 2011. Columbia, USA: National Center on Addiction and Substance Abuse at Columbia University; 2011. Available from: https://drugfree.org/wp-content/uploads/drupal/National-survey-of-american-attitudes-on-substance-abuse-XVI-teens-and-parents.pdf
[Last accessed on 12 Apr 2022].
Ogel K, Corapcioglu A, Sir A, Tamar M, Tot S, Dogan O, et al
. Tobacco, alcohol and substance use. Prevalence among elementary and secondary school students in nine cities of Turkey. Turk J Psychiatry 2004;45: 88-9.
Millar WJ, Hunter L The relationship between socioeconomic status and household smoking patterns in canada. Am J Health Promot 1990;5:36-43.
Conway KP, Vullo GC, Nichter B, Wang J, Compton WM, Iannotti RJ, et al
. Prevalence and patterns of polysubstance use in a nationally representative sample of 10th graders in the united states. J Adolesc Health 2013;52:716-23.
Sharma R, Grover VL, Chaturvedi S Tobacco use among adolescent students and the influence of role models. Indian J Community Med 2010;35:272-5.
Ray R, Mondal AB, Gupta K, Chatterjee A, Bajaj P The Extent, Pattern and Trends of Drug Abuse in India: National Survey. New Delhi: United Nations Office on Drugs and Crime (UNODC) and Ministry of Social Justice and Empowerment, Government of India; 2004.
Sinha DN, Palipudi KM, Jones CK, Khadka BB, Silva PD, Mumthaz M, et al.. Levels and trends of smokeless tobacco use among youth in countries of the World Health Organization South-East Asia Region. Indian J Cancer 2014;51 Suppl 1:S50-3.
Muttappallymyalil J, Divakaran B, Thomas T, Sreedharan J, Haran JC, Thanzeel M Prevalence of Tobacco Use Among Adolescents in India. Asian Pacific J Cancer Prev 2012;13:5371-4.
Taran SJ, Taran R, Soroshe S, Bhandari V A cross-sectional study to assess the prevalence and awareness of tobacco consumption among school students in a cosmopolitan city of India. Int J Contemp Pediatr 2016;3:86-90.
Bagchi NN, Ganguly S, Pal S, Chatterjee S A study on smoking and associated psychosocial factors among adolescent students in Kolkata, India. Indian J Public Health 2014;58:50-3.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]