National GYTS in Nepal in 2007 was conducted among students from 13 to 15 years age group only whereas our study included students from 14 to 19 years. Almost equal proportions of male and female students were involved in our study. Participants belonging to Janajati ethnicity were predominant. Similar study from Pokhara, Nepal reported nearly equal proportions of males and females with predominance of Brahmin ethnicity.9
The prevalence of ever use of tobacco in this study was more compared with a study from western Nepal.7
The prevalence of ever smokers of tobacco (17.9%) was high compared with National GYTS where 7.9% of students had ever smoked.4
Regarding tobacco chewing, prevalence in our study (8%) was low compared with a similar study among college students from western Nepal (21.2%).13
Inclusion of students from secondary and higher-secondary level in our study could have attributed to this difference in prevalence.
The mean age for tobacco use initiation (smoking and chewing) in our study was found to be in consistency with studies from Kathmandu, Noida, and Kerala, India where the mean ages of onset were 14.15, 12.4 and 13.2 years, respectively.10
Early- and middle-adolescents are more vulnerable to initiation of tobacco use; hence, a target group is highlighted for early intervention to reduce the uptake of this habit.
Our study has shown that more than half of the adolescent tobacco users prefer public places as their most common location of tobacco use and shops as the most common source. Similar results have been obtained in the study from Pokhara, Nepal, which showed that most of the respondents (66.7%) smoked in public places like tea stalls or restaurants and majority purchased tobacco from the shops.7
National GYTS in 2007 reported that more than two-thirds (69.5%) of the students were not refused tobacco purchase in stores because of their age.4
According to a study from Kerala, India, the most preferred places for smoking were friends’ house and public places.6
Provision of unrestricted access to tobacco products in the shops especially to the adolescents including minors, and its open use in public places pose a great challenge to the implementation of the regulations of the antitobacco law in Nepal.
Curiosity, relieving tension and pressure from friends were the major reasons for initiating tobacco use in this study. In developing countries, documented factors implicated in the initiation of tobacco use among youth include experimentation, peer pressure and sense of feeling more matured.16
Students in late adolescence were more likely to consume tobacco compared with those in middle adolescence. Similar results were seen in a study from Kerala where students aged 16 years and above were nearly three times more likely to be tobacco users compared with those who were 13-year olds (adjusted OR=2.9, CI 1.6 to 5.3).6
Tobacco use is more common in later adolescence, thus cessation attempts need to be focused in these groups.
Type of family can influence tobacco use. Ever use of tobacco was two times more likely in students belonging to nuclear families compared with joint families (adjusted OR=1.96, 95% CI 1.11 to 3.45) in a study from India.8
However, in our study tobacco use was less likely among students belonging to nuclear families. Close contact among parents and children in nuclear families might play a protective role against taking up risky behaviour like tobacco use.
Prevalence of ever-tobacco use of any tobacco product was 19% (95% CI 16.6 to 21.4) for government school students compared with 10.1% (95% CI 7.7 to 12.5) for private school students in a study among urban youth of India.17
As students from higher SES tend to study in private schools and those from lower SES study in government schools, findings from our study highlights the socioeconomic differences that exist in tobacco use in our setting.
Higher odds of tobacco use existed among boys as compared with girls. Similar difference of prevalence between males and females was seen in other studies conducted in Nepal and abroad.8–10
Male participants were more likely to ever smoke than female participants in a study from western Nepal (adjusted OR=4.0; 95% CI 2.9 to 5.6)19
and Haryana, India (adjusted OR=4.67; 95% CI 1.91 to 11.4).20
Tobacco use can be considered as part of a constellation of risk-taking behaviours that is more prevalent among men.21
In context of Nepal, teen smoking is viewed as an acceptable behaviour for boys but not for girls, especially among the unmarried. Large proportions of teens in Asian countries, especially boys, pick up smoking as a part of normal behaviour associated with their transition to adulthood.22
This striking gender differences in tobacco use was also observed among Nepalese population aged 15–59 years.23
However, the rising trend of tobacco use among the girls should not be ignored. It has been mentioned that when the prevalence of smoking among teen girls increases in Asian countries, it seems to increase first in metropolitan areas. Continuing modernisation is likely to narrow the gender differences in smoking and is likely to result in high prevalence of smoking among teen girls in Asian countries.22
Dharan, a town on the verge of rapid urbanisation is likely to face this scenario in the near future.
Janajatis were two times more likely to consume tobacco compared with Brahmins/Chhetris in our study. Janajatis is the broad ethnic group comprising castes mainly from the hills of Nepal. Tobacco chewing was significantly higher among the hill native castes which included Rai, Limbu, Magar, Tamang, Gurung, whereas smoking was significantly higher among the hill occupational castes which included Biswakarma, Pariyar and Sarki in a study conducted among female population of Dharan.24
Nepal Adolescent and Youth Survey in 2010 showed similar results in which relatively advantaged Janajatis were found to have a higher prevalence of liquor (32.60%) and tobacco use (16.62%) followed by disadvantaged Janajatis (27.83% and 13.71%, respectively).25
The population of hill region is more diverse than the Terai region in its ethnic, caste and religious composition and the attitude towards smoking is more permissive among the people from the hills.26
This might be a possible explanation for the higher prevalence of tobacco use seen among the Janajatis in various studies across Nepal including ours.
Greater likelihood of using tobacco with higher amount of pocket money was reflected in other studies as well.5
Having some amount of disposable money at hand might predispose the adolescents towards use of tobacco by easing the access. However, asking for more pocket money to buy tobacco products could also be the reason behind the significance of the association for which further studies are required.
The present study had few limitations. Even though the participation in the study was entirely voluntary with an assurance of non-disclosure of identity and confidentiality, chances of bias may occur in the findings as the data were collected through self-administered questionnaire. The assessment of the tobacco-use status was based entirely upon the response given by the subject believing that false reporting was very unlikely. However, this was not validated by biomarkers. Sample size of the study was small and limited to school-going adolescents of Dharan only, hence cannot be generalised to the rest of eastern Nepal. Peer pressure was found to be one of the reasons to start tobacco use but was not included as part of the analysis. The temporal association between the independent variables and tobacco use could not be established owing to the study design being cross-sectional.