Evaluating Knowledge and Attitudes towards Tobacco use among Urban High School Students in Kerala, India: Implications for Targeted Prevention Strategies

 

Sinu Jose¹*, Maneesha C Cyriac², Gayathri P V

¹Assistant Professor, Government College of Nursing, Kottayam, Kerala, India.

²Bel-Air College of Nursing, Panchgani, Maharashtra, India.

³Associate Professor, Government College of Nursing, Kottayam, Kerala, India.

 

ABSTRACT:

Objectives: Adolescence is a critical period marked by susceptibility to increased tobacco, alcohol, and drug use. India, the world's third-largest tobacco consumer and producer, faces rising tobacco use rates, particularly among the youth. This study aimed to assess the knowledge and attitudes regarding tobacco use of high school students in Kerala, India. Methods: A cross-sectional study was conducted in three randomly selected urban high schools in Kerala. Data were collected using a structured questionnaire assessing students' background information, knowledge about tobacco use, and attitudes toward tobacco. Statistical analysis included chi-square tests and t-tests. Results: High school students in Kerala, India, had a moderate understanding of tobacco use, scoring 70.92% on average. They comprehended diseases caused by smoking and smokeless tobacco harms but lacked knowledge about psychological and social effects and treatment options. Attitudes varied, with 55.9% favoring tobacco control and 44.1% opposing. Significant factors affecting knowledge and attitudes included family type, parental tobacco use, perceived economic status, and age. Nuclear families, non-tobacco-using parents, better economic status, and older age correlated with higher knowledge and more favorable attitudes. Conclusion: Understanding the factors is essential for designing targeted interventions and prevention programs to promote healthier attitudes towards tobacco use among high school students. Tailored interventions should consider age-specific needs, parental involvement, and economic factors to effectively combat tobacco use among adolescents.

 

 

INTRODUCTION:

Adolescents (10–19 years) constitute about 23% of India’s population. This stage of life is marked by peer influence, stress, experimentation, and risk-taking, which often lead to early initiation of smoking, alcohol, or drug use. Easy availability of such substances increases temptation, and unchecked use may develop into addiction. Tobacco consumption, is a major public health concern, with secondhand smoke further exposing non-smokers to health risks and increasing the likelihood of initiation¹.

 

India ranks third globally in tobacco production and consumption, with 182 million users contributing significantly to the nation's disease burden despite ongoing efforts^1,2. Chewing tobacco is particularly linked to head, neck, lung, and oral cancers, as well as serious oral health issues³. While a 2019 survey showed a 42% decline in current tobacco use among students (grades 8-10) compared to 2009, with 8.5% being current users, alarming initiation ages occurred before age 10⁴.

 

Despite bans, tobacco-related diseases and deaths are increasing in Kerala, with tobacco and alcohol strongly linked to half of the state's nearly 35,000 annual cancer cases, primarily affecting men's mouth, throat, and lungs. Nationally, tobacco-attributable deaths are projected to rise dramatically by 2020. Preventing young people from starting tobacco use is identified as the most effective strategy to curb India's non-communicable disease burden⁵.

 

The attempts to identify the knowledge and attitude of the adolescents towards tobacco consumption needed to conduct periodically to plan and organize effective health education programmes according to the dynamic situations. Male students are more prone to abuse the tobacco, present study was planned to conduct among high school boys in urban area to identify the knowledge and attitude towards tobacco abuse.

 

MATERIALS AND METHODS:

Study Design:

A cross-sectional study was conducted among high school students studying in 3 randomly selected urban high schools of middle Kerala, five classes were selected randomly each from 9^th and 10^th standards and included all the students who presented on the day of the study.

 

Sample Size:

Global Youth Tobacco Survey conducted identified a prevalence of tobacco uses among youth as 14.6% [4], so sample size was calculated as 192 with an absolute precision of 5% with a power of 80%. We distributed the questionnaire among 240 students, and got 100% completed responses.

 

Data Collection Tools:

A structured and pretested questionnaire was developed following an extensive review of the literature and expert consensus. The questionnaire comprised two major sections: background information of the students and 14 items designed to assess knowledge regarding tobacco use and its adverse effects. Each correct response was awarded one point. Based on the total score, students were classified as having good knowledge (≥10) or poor knowledge (<9). The knowledge-related items were further categorized into five domains: (i) tobacco use, (ii) adverse effects, (iii) withdrawal symptoms, (iv) tobacco addiction, and (v) treatment facilities. Pretesting among 30 students established the internal consistency of the tool (r = 0.82).

 

Assessment of Attitudes:

Students’ attitudes toward tobacco use were measured using a five-point Likert scale adapted from the Global Youth Tobacco Survey (GYTS) Core Questionnaire. This section consisted of 12 statements. For positive statements (items 4, 6, 8, 9, 11, and 12), participants rated their agreement from 1 (Strongly Disagree) to 5 (Strongly Agree). For the remaining items, scoring was reversed, with 1 indicating Strong Agreement and 5 indicating Strong Disagreement. The internal consistency of this scale, assessed during the pilot study, yielded a Cronbach’s alpha of 0.72.

 

Method of Data Collection:

Prior permission was obtained from the school authorities, explained that participation to the study was voluntary and kept anonymous. The purpose of the study and anonymity of the data collected were explained to the participants and those given informed assent was included in the study. Ethical clearance was obtained from the institutional ethical clearance committee (ethical clearance no-IEC No.88/2012 dated 20/06/2012).

 

Data Analysis:

The Data collected were analyzed using SPSS version 22, using both descriptive and inferential statistics. Chi-square test was used to demonstrate cross tabulation.

 

RESULTS:

In this study we included 240 high school students for analysis, majority of our participants were 16 years old, 90% of the students were residing in rural areas and all were living with their parents and family. As depicted in the table 1, majority (70%) belonged to the nuclear family and sixty-six percentage of students self-reported tobacco use among the family members. Source of information about the adverse effects of tobacco consumption mainly consisted of television, movies and internet.

 

Table 1: Socio-demographic status of the students

 

Table 2: Knowledge of high school students about tobacco abuse

Knowledge of high school students regarding tobacco abuse	Mean ± SD	Mean percentage
Concepts of tobacco abuse	2 ± 0.97	66.66%
Diseases caused by tobacco smoking	2.07 ± 0.87	69%
Adverse effects of smokeless tobacco products	3.70 ±0.47	92.5%
Psychological and social impact of tobacco abuse	1.23 ± 0.57	61.5%
Treatment modalities	1.30±0.64	65%
Overall Knowledge	9.93±2.62	70.92%

 

 

Table 2 shows that high school students demonstrated moderate overall knowledge about tobacco misuse (mean score 9.93; 70.9%). They showed good awareness of the harmful effects of smokeless tobacco (3.70) but limited knowledge of psychological and social impacts (1.23) and treatment options (1.30). Knowledge of tobacco use (2.00) and related diseases (2.07) was moderate, indicating the need for targeted educational interventions.

 

Table 3 shows that age and place of residence had no significant effect on students’ knowledge of tobacco use. However, students from nuclear families (χ² = 58.035, p < 0.001) and those with non-tobacco-using parents (χ² = 41.543, p < 0.001) demonstrated significantly higher knowledge. Perceived family economic status also influenced awareness, with students reporting a “good” status scoring better than those with a “poor” status (χ² = 7.10, p = 0.028).

 

Table 3: Association of knowledge regarding tobacco use among high school students and their socio-demographic characteristics

Variables	Knowledge levels		χ² (df)	P value
	Good knowledge	Poor Knowledge
Age
14 years	19 (7.92%)	13 (5.42)	1.735 (2)	0.420
15 years	45 (18.75%)	43 (18%)
16 years	72 (30%)	48 (20%)
Type of family
Nuclear	122 (50.83%)	46 (19.2%)	58.035***(1)	0.0001
Extended	14 (5.83%)	58 (24.5%)
Place of residence
Urban	16 (6.66%)	8 (3.33%)	0.762 (1)	0.38
Rural	124 (51.66%)	92 (38.33%)
Parental use of tobacco products
Yes	113 (47%)	45 (18.75%)	41.543***(1)	0.001
No	23 (9.58%)	59 (24.6%)
Perceived family economic status
Good	7 (3%)	16 (6.66%)	7.10* (2)	0.028
Average	60 (25%)	43 (18%)
Poor	68 (28.3%)	45 (18.75%)

 

 

Tables 4 shows that 55.9% of students had favorable and 44.1% unfavorable attitudes toward tobacco use, with a mean score below 40, indicating mixed perceptions. Favorable attitudes were noted toward statements on effective treatments for tobacco addiction (71.7%) and the need for a legal ban (55.3%). Neutral attitudes were common for misconceptions such as tobacco being dangerous only to the elderly (27.7%) or improving confidence (18%). Unfavorable attitudes were evident toward beliefs that tobacco enhances physical performance (mean score 2.29).

Table 4: Attitude of high school students towards tobacco use

Attitude score	f(%)	Mean ± SD
Favourable attitude (score 40-60)	55.9 %	40.74 ±9.45
Unfavourable attitude (score<40)	44.1 %

Table 5 shows that age significantly influenced attitudes toward tobacco use (χ² = 5.991, p = 0.050), with 14-year-olds reporting the most favorable attitudes. Place of residence showed no effect (χ² = 1.524, p = 0.216). Parental tobacco use was strongly associated with attitudes (χ² = 41.543, p < 0.001): students with non-tobacco-using parents reported more favorable (31%) and fewer unfavorable attitudes (12.7%) compared to those with tobacco-using parents (25% vs. 31.3%). Perceived family economic status also influenced attitudes (χ² = 7.10, p = 0.028), with students from “good” or “average” backgrounds showing more favorable attitudes than those from “poor” families.

 

Table 5: Association of attitude regarding tobacco use among high school students and their socio-demographic characteristics

Variables	Attitude towards tobacco use		χ² (df)	P value
	Favourable	Unfavourable
Place of residence
Urban	20.67	19.33	1.524 (1)	0.216
Rural	35.33	24.67
Parental use of tobacco products
Yes	25	31.33	41.543***(1)	0.001
No	31	12.67
Perceived family economic status
Good	24	23.33	7.10*(2)	0.028
Average	25.34	17.67
Poor	6.66	3

 

DISCUSSION:

Adolescence is a critical stage in life, where habits and behaviors formed can have lasting health consequences. Understanding the knowledge, attitudes, and behavioral factors influencing tobacco use is essential for identifying risks and designing effective prevention strategies.

 

This study found that students demonstrated fair awareness of tobacco-related diseases and the harmful effects of smokeless tobacco, consistent with findings by Raina et al. and Xu et al. ^6,7. However, they lacked knowledge of its psychological, social impacts, and treatment options, in line with Multani et al. ⁸. Peer and media influences, coupled with adolescents' tendency to prioritize immediate gratification, often highlight short-term benefits of tobacco (like refreshment or perceived attractiveness/sports performance), overshadowing long-term harms. This focus is reinforced by limited educational coverage and students' perception that psychological and social aspects are less relevant ⁹.

The findings show diverse attitudes among students toward tobacco. Many supported treatments and legal bans, while others held neutral or unfavorable views. Peer groups strongly shape attitudes, with pro or anti-tobacco friends influencing compliance or resistance ⁹. Similarly, parental behavior plays a key role: students with parents opposing or quitting smoking were more supportive of treatments and bans, while those with smoking parents tended to show the opposite ¹⁰.

 

Students’ attitudes toward tobacco are shaped by multiple factors. Tobacco companies often use sophisticated marketing to portray smoking as appealing ⁹, while pro-smoking media exposure can make it seem glamorous or beneficial ¹⁰. In contrast, comprehensive school-based education programs are linked to more neutral or unfavorable attitudes ⁹. Personal or family experiences with tobacco use or addiction further reinforce these perceptions, underscoring the role of lived experiences in shaping attitudes.

 

Students from nuclear families with non-smoking parents and those perceiving their family’s economic status as good showed greater awareness of tobacco abuse. Stable family environments and positive parental role models reinforce anti-tobacco messages ^11,12, whereas extended families with smoking members may expose students to conflicting influences ¹³. Economic wellbeing further supports awareness by providing better access to educational resources.

 

Age, parental tobacco use, and perceived family economic status were found to significantly influence students’ attitudes toward tobacco, while place of residence had little impact. Peer influence plays a major role during adolescence, often outweighing parental guidance in shaping behaviors and attitudes toward smoking. Between ages 14 and 16, as students form their own beliefs, parental influence tends to diminish, which may explain the increasing diversity of opinions with age and the reduced effect of parental tobacco use ¹³.

 

Family economic status significantly influences students' tobacco attitudes by shaping their exposure to anti-smoking messages and reliable information, with higher economic backgrounds providing greater access ^14-16. Adolescents from lower-status families often face more limited resources and different social influences compared to their wealthier peers. While urban and rural settings once exhibited disparities in tobacco vulnerability, widespread mass media and internet access have driven convergence in information availability. Additionally, initiatives like improved basic healthcare facilities and awareness campaigns have helped narrow geographical gaps in tobacco knowledge ^{14, 17-21}.

 

High schools bring together students from diverse backgrounds under standardized educational programs, which aim to deliver consistent information about the risks of tobacco use regardless of residence. As a result, education and awareness efforts may outweigh regional differences. This study provides important insights into students’ knowledge and attitudes toward tobacco, offering a foundation for designing more effective prevention strategies ^22-25.

 

LIMITATIONS:

The sample size was limited and may not fully represent the broader high school population. Socio-demographic characteristics and cultural factors likely vary across regions, but regional differences were not considered. The data relied on self-reporting and may be subject to response bias.

 

RECOMMENDATIONS:

Future interventions should be tailored to age-specific needs, strengthen parental involvement, and address economic factors to foster healthier attitudes toward tobacco use. Educational programs must also target misconceptions and enhance awareness of tobacco’s harmful effects.

 

CONCLUSION:

The study reveals variations in high school students’ knowledge and attitudes toward tobacco use, underscoring the need for targeted educational campaigns and interventions to foster more informed and health-conscious behaviors among adolescents.

 

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Received on 14.03.2025         Revised on 20.08.2025 Accepted on 24.11.2025         Published on 21.02.2026 Available online from February 23, 2026 Asian J. Nursing Education and Research. 2026;16(1):43-48. DOI: 10.52711/2349-2996.2026.00010 ©A and V Publications All right reserved
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