Tobacco Consumption and its Associated Factors among Nepalese Students

All published articles of this journal are available on ScienceDirect.

RESEARCH ARTICLE

Tobacco Consumption and its Associated Factors among Nepalese Students

Pragati Sharma1 Sandip Pahari1 Shiva Raj Acharya2 , * Open Modal Deog Hwan Moon2 Yong Chul Shin3
Authors Info & Affiliations
The Open Public Health Journal • 15 Oct 2021 • RESEARCH ARTICLE • DOI: 10.2174/1874944502114010446

Abstract

Background:

Tobacco smoking is one of the major issues among the adolescent population worldwide. WHO has estimated that tobacco use causes six million deaths worldwide each year and predicts reaching eight million by 2030. Our study aims to assess the proportion of tobacco use and its associated factors among Nepalese students.

Methods:

A cross-sectional analytical study was conducted among 430 students in Syangja, Nepal. Samples were selected through the cluster sampling technique. Data were collected by a self-administered questionnaire. Chi-square (χ2) test was used to find out the associated factors of tobacco consumption.

Results:

The prevalence of tobacco usage was found to be 22.8% (males 37.2%, females 8%). Students were regularly exposed to tobacco smoking in public places (70.3%) and at home (62.2%). Peer pressure (62.3%) was the most influencing factor for tobacco consumption, followed by experimentation (18.2%) and tobacco advertisements (7.8%). Cigarette (75.5%) and Hookah (74.5%) were the most common type of tobacco consumed by the participants. Tobacco consumption was higher among private school students (24.5%) than government school students (19.6%).

Conclusion:

Gender, family type, occupation, and pocket money were associated with tobacco usage (p<0.05). Although the majority of students were aware of the negative health impacts of tobacco use, the usage of tobacco products is still prevalent among Nepalese adolescent students. School-based health education and intervention programs should be implemented to reduce the habit of tobacco consumption.

Keywords: Tobacco use, Smoking, Adolescents, Students, Smokers, Pocket money.

1. INTRODUCTION

Tobacco use is characterized as utilizing any tobacco item, either smoked or smokeless [1]. Tobacco smoking is named as the burning of the tobacco leaves and breathing in of the smoke. Chewing tobacco, wet snuff, and dry snuff are examples of smokeless tobacco consumed through the mouth or nose without combustion or burning [2]. Tobacco smoking is a preventable health concern that also causes financial problems across the world [3, 4]. China daily smokers start smoking before the age of 20, where peer influence is one of the major factors to consume tobacco [5, 6]. Because of the powerless authorization of tobacco control measures, the easy accessibility and affordability of these items are the main leading to the rise of the epidemic of tobacco use in the youth [7].WHO estimated that in 2013, the worldwide prevalence of current tobacco smoking was 21.2%. WHO has estimated that tobacco use (smoking and smokeless) causes six million deaths worldwide each year and predicts to reach 8 million by 2030 [8, 9]. About 1.1 billion individuals smoke worldwide, 80% of whom lived in low and middle-income countries [10, 11]. In India, the overall prevalence of tobacco consumption was 48.9% [12]. There is a connection between smoking and many diseases such as coronary artery disease, lung cancer, bladder cancer, pulmonary emphysema, peripheral vascular disease, and neonatal mortality [13]. Furthermore, the U.S Surgeon General report proposes that smoking influences the menstrual function of women by increasing the danger of dysmenorrhea, amenorrhea, and irregular menstruation. The Family Smoking Prevention and Tobacco Control Act of 2009 (also known as the Tobacco Control Act) approved the FDA to manage the manufacture, distribution, and marketing of tobacco products [14]. In Nepal, adolescents comprise one-fifth (22%) of the total population [15-24]. In Nepal, behavior, attitude, and imitation from parents and peers are the most influencing factors for tobacco consumption [1]. Peer influence is one of the major factors where adolescents are more likely to smoke if they have friends who smoke [5]. Both smoking and smokeless tobacco are quite high among youth in the Southeast Asian Region. In South Asian Countries, tobacco use is prevalent among male students from Bangladesh (9.1%), Bhutan (28.6%), India (16.8%), Maldives (8.5%), Nepal (13.0%), Pakistan (12.4%), and Sri Lanka (12.4%) [25]. Geographical variation comprises various parts of the country. Based on the studies, female smoking prevalence was 71.6% in the Mountain region and 12.9% in Eastern Terai of Nepal [10, 26].

1.1. Rationale of the Study

Tobacco consumption is a rapidly growing problem of public health concern, leading to the causes of preventable morbidity and mortality. Tobacco consumption is increasing at a high rate among youth and is one of the serious problems affecting the lungs. College students are in the transition phase. They start to consume tobacco from this stage due to peer pressure, lack of knowledge, etc. They are exposed to social media, so they are more prone to tobacco consumption. Most of the people are from low and middle-income countries due to the lack of knowledge about the health risks of tobacco consumption. Nepal is one of the developing countries of the world which is facing the burden of diseases regarding respiration due to tobacco consumption. In Nepal, the proportion of deaths due to non-communicable diseases are at a highly increased rate. People are still consuming tobacco products besides knowing about health hazards due to tobacco consumption. There is still a lack of proper implementation of laws focusing on the usage of tobacco products. Limited studies have been carried out to determine the factors associated with tobacco users among college students in Nepal. Therefore, we aim to conduct this study to find out the current scenario of tobacco consumption among students of higher secondary school. Our findings will be helpful to concerned authorities to plan and implement necessary programs and policies for addressing tobacco product usage among the young population.

2. METHODOLOGY

2.1. Study Design and Population

A cross-sectional analytical study was conducted to assess the proportion of tobacco use (both smoked and smokeless tobacco products) and its associated factors among 430 higher secondary level students in Syangja, Nepal. Students from grades 11 and 12, both male and female students, were included in the study. Students who refused their participation were excluded.

2.2. Sampling Technique and Sample Size

A total of 13 higher secondary schools were included in the study. Out of the 13 schools, six schools were selected by simple random sampling method. Faculty were chosen randomly with lottery methods. Finally, a cluster sampling technique was used to collect the study samples. The sample size was calculated using the formula,

Z = standard normal variable at 95% CI (1.96), N = Total number of higher secondary level students (1388), p = estimated proportion (p = 0.209) based on the previous similar study [27], q = 1-p, d = desirable error (0.05). With the application of 10% non-response rate, the sample size (n) for this study was 215. The final sample size for this study with the design effect for cluster sampling (215* 2) was 430.

2.3. Data Collection and Management

A self-administered questionnaire was used for the purpose of data collection. Face to face interview was conducted from August to October 2019. Pretesting was done on 10% of the total sample size in a similar setting. Tools were developed and translated into simple and clear English language and back-translated into the Nepali language. To minimize the limit error, 10% of the entered data were randomly selected using decision analyst software and manually checked. If the error exceeds 1%, the collected data were re-entered. Descriptive data analysis was carried out in terms of frequency and percentage. Chi-square (χ2) test was used to find out the associated factors of tobacco consumption. Data entry, management, and analysis were done with EpiData 3.1 and SPSS Ver [20].

2.4. Study Variables

Age, sex, ethnicity, school type, occupation, and income were considered socio-demographic variables for the study. The reasons for tobacco consumption and health hazards due to tobacco consumption were assessed as knowledge of related factors. Peer pressure, advertisements, and perceptions towards tobacco consumption were assessed as exposure to behavioral factors. Tobacco consumption among higher secondary students was assessed as the dependent variable of this study.

Ethical approval was approved by the Institutional Review Board (IRB) of Pokhara University. (IRB Ref. No. 39/076/077). Informed consent was taken from each participant's parent before the interview. Confidentiality was maintained throughout the study. Permission was also taken from the concerned authorities of Syangja, Nepal, to conduct this study.

2.5. Operational Definitions

Cigarettes: A thin cylinder of shredded tobacco that is wrapped in paper, lit and smoked.

Bidi: Cigarettes consisting of sun-dried tobacco flakes rolled in a tendu leaf and tied with a string at one end.

Khaini: A form of chewing tobacco-containing slake lime.

Paan masala: A mixture of chopped areca nut, lime, and other ingredients, including tobacco for chewing, wrapped in a betel leaf.

Gutkha: A form of chewing tobacco preparation made of crushed areca nuts.

Hookah: Hookahs are water pipes used to smoke specially made with different flavors like apple, mint, cherry, watermelon.

Surti: A sun-dried form of tobacco flakes.

3. RESULTS

Table 1 demonstrates the socio-demographic characteristics of the respondents. The majority of students (94.4%) were of age between 15 and 18 years. The majority of the participants were followers of the Hindu religion. Among the participants, 64.4% of the students were from government schools, whereas 35.6% were from non-government schools. The study found that the major occupation of the participants’ fathers was a job abroad, whereas most mothers were involved in agriculture. The nuclear family type was found to be common among the participants, followed by a joint type of family.

The study found that the majority (80.2%) consumed tobacco in the form of surti followed by smoking cigarettes (47.2%), gutkha (41.6%), bidi (26%), paan masala (25.8%), khaini (73.5%), and hookah (23.3%). Almost all of the students claimed to have knowledge about the harmful effects of tobacco. The majority of the participants told mouth cancer as a type of health problem due to the consumption of tobacco followed by lung cancer, gum, and teeth problem. Table 2 shows that the majority of the participants (77.2%) did not consume tobacco, whereas 22.8% consumed different tobacco products. The majority of participants who consumed tobacco did so due to the peer pressure followed by family members, for experimental purposes, advertisements, and stress. Nearly three-quarters of students who consumed tobacco did so using cigarettes and hookah.

More than half (51%) of the respondents tried consuming tobacco products at the age of 13-15 years. About 32.7% of students regularly consumed tobacco. The majority of the participants (66.5%) were occasionally exposed to Second Hand Smoking (SHS) at public places, whereas 43.7% were exposed at home, as shown in Table 2. Television was the most influencing advertisement medium for tobacco consumption among the respondents, followed by cinema hall and radio.

Table 1.
Socio-demographic characteristics of the respondents.
Variables Frequency Percentage (%)
Age
  15-18 406 94.4
  19-22 24 5.6
Mean=16.83, Median=17, S.D.=1.114, Mini=15, Max=22
Gender
  Male 218 50.7
  Female 212 49.3
Religion
  Hindu 392 91.2
  Muslim 9 2.1
  Christian 5 1.2
  Buddhism 24 5.6
Type of School
  Non-Government 153 35.6
  Government 277 64.4
Pocket Money (NRs)
  <1500 (<12.75$) 308 71.6
  >1500 (>12.75$) 122 28.4
Ethnicity
Brahmin/Kshetri 165 38.4
Janajati 196 45.6
Dalit 60 14
  Muslim 9 2.1
Family Type
  Nuclear 230 53.5
  Joint 174 40.5
  Extended 26 6
Fathers’ Occupation
Agriculture 88 20.5
  Civil Service 77 17.9
  Business 69 16
  Private Services 59 13.7
  Abroad 135 31.4
  Labor 2 0.5
Mothers’ Occupation
Agriculture 148 34.4
  Civil Service 12 2.8
  Business 70 16.3
  Private Services 23 5.3
  Abroad 1 0.2
  Unemployed 176 40.9
Table 2.
Tobacco consumption among the study population.
Variables Frequency Percentage
Tobacco Consumption
Yes 98 22.8
No 332 77.2
Influencing Factors for Tobacco Consumption (N=98)
Peer-Pressure 48 62.3
Family-members 2 2.6
Experimentation 14 18.2
Advertisements 9 11.7
Stress 4 5.2
Types of Tobacco Consumed*
Cigarette 74 75.5
Surti 10 10.2
Khaini 16 16.3
Paan masala 25 25.5
Bidi 13 13.3
Hookah 73 74.5
Age of the Initiation (N=98)
<10 6 6.1
10-12 10 10.2
13-15 50 51.0
>15 32 32.7
Frequency of Tobacco Consumption (N=98)
Regular 32 32.7
Occasional 14 14.3
Consumed in the past 23 23.5
Experimental purpose 29 29.6
Influence of Tobacco Advertisements (N=98)
Yes 59 60.2
No 39 39.8
Most Influencing Tobacco Advertisements*
Television 42 70
Mobile phone 11 18.3
Radio 17 28.3
Newspaper 15 25
Poster 12 20
Cinema Hall 23 38.3
Expose to SHS at Public Places
Regularly 37 8.6
Occasionally 286 66.5
Never 107 24.9
Expose to SHS at Home
Regularly 37 8.6
Occasionally 118 43.7
Never 205 47.7
Knowledge about the Harmful Effects of Tobacco
Yes 417 97
No 13 3
Knowledge About Health Problems Due to Tobacco Consumption*
Cough 173 41.5
Asthma 172 41.2
Problem in Gum 93 22.3
Problem in teeth 190 45.6
Lung Cancer 283 67.9
Wound in mouth 219 52.5
Mouth Cancer 306 73.4

Study results showed that 43.9% of the respondents consumed tobacco in hotels/restaurants, followed by college (20.4%), canteen (18.4%), public places (8.2%), home (5.1%), toilet (3.1%), and cinema hall (1.0%). It was found that gender (p-value 0.000, χ2 = 51.85), family type (p-value 0.000, χ2 = 20.45), mothers' occupation (p-value 0.002, χ2 = 16.59) and pocket money (p-value 0.001, χ2 = 11.32) were significantly associated with tobacco consumption while other variables were not statistically significant. Our study investigated the association between exposure to behavioral actions and tobacco consumption. It was found that exposure to Second Hand Smoking (SHS) at home (p-value 0.000, χ2 = 52.55) and public places p-value 0.000, χ2 = 36.51) were significantly associated with tobacco consumption (Table 3).

Table 3.
Association of tobacco consumption with socio-demographic factors and exposure to behavioral actions.
Variable Tobacco Consumption Total χ2 df P-Value
Yes No
N
(98)		 % (22.8) N
(332)		 % (77.2)
Age
15-18 91 22.4 315 77.6 402 0.58 1 0.443
18-22 7 29.2 17 70.8 28
Gender
Male 81 37.2 137 62.8 218 51.85 1 0.000*
Female 17 8 195 92 212
Family Type
Nuclear 36 15.7 194 84.3 230 20.45 2 0.000*
Joint 13 50.0 13 50.0 26
Extended 49 28.2 125 71.8 174
Ethnicity
Brahmin/Chhetri 30 18.2 135 81.8 165 3.93 3 0.269
Janajati 48 24.5 148 75.5    196
Dalit 17 28.3 43 71.7     60
Muslim 3 33.3 6 66.7 9
Mothers’ Occupation
Agriculture 21 14.2 127 85.8 148 16.59 4 0.002*
Service 7 20.0 28 80.0 35
Business 14 20.0 56 80.0 70
Abroad 1 100.0 0 0.0 1
Unemployed 55 31.2 121 68.8 176
Fathers’ Occupation
Agriculture & labor 14 15.6 76 84.4 90 6.62 3 0.085
Service 27 19.9 109 80.1    136
Business 18 26.1 51 73.9     69
Abroad 39 28.9 96 71.1    135
Pocket Money (NRs)
<1500 (<12.75$) 57 18.5 251 81.5 308 11.32 1 0.001*
>1500 (>12.75$) 41 33.6 81 66.4 122
Type of School
Government 30    19.6 123 80.4 153 1.36 1 0.242
Non-Government 68    24.5 209 75.5 277
Fathers’ Education
Illiterate 2    66.7 1 33.3 3 1.27 1 0.26
Literate 96    22.5 331 77.5 427
Mothers’ Education
Illiterate 6    22.2 21 77.8 27 0.005 1 0.942
Literate 92    22.8 311 77.2 403
Exposed to SHS at Home
Regularly 26   70.3 11 29.7 37 52.55 2 0.000*
Occasionally 31   16.5 157 83.5 188
Never 41   20.0 164 80.0 205
Exposed to SHS at Public Places
Regularly 23   62.2 14 37.8 37 36.51 2 0.000*
Occasionally 58   20.3 228 79.7 286
Never 17   15.9 90 84.1 107

The perceptions about tobacco consumption were measured on a five-point scale on given statements. Students were asked to mark any one option among “strongly agree,” “agree,” “can't say,” “strongly disagree,” and “disagree.” Finally, the responses “strongly agree” and “agree” are merged into agree, and responses “strongly disagree” and “disagree” were merged into disagree.

The proportion of respondents who agreed with the statement that ‘tobacco users have more friends’ was found to be higher than those who disagreed, but there was not any significant association with the gender of the participants. The proportion of students who studied in government schools agreed with the statement that ‘tobacco users have more friends’ was found to be higher (86.3%) than those who studied in non-government schools. The study showed that most of the participants agreed with the statement that ‘smoking should be banned in public places’ and found it to be significantly associated with the gender of the participants (p-value 0.001, χ2 = 16.841). The proportion of students who studied in government school agreed with the statement that ‘smoking should be banned in public places’ was found to be higher (94.8%) than those who studied in non-government schools. Similarly, the proportion of the male participants who agreed on both perception statements about tobacco consumption was higher as compared to female participants, as shown in Table 4.

Table 4.
Factors associated with perception towards tobacco consumption.
Variable Smoking should be banned in public
places 		Total χ2 df p-value
      Agree Can’t say Disagree
Gender
Male 195 89.4%    1 0.5%   22 10.% 218 16.841 2 0.001*
Female 171 80.7%   10 4.7%   31 14.% 212
Type of school
Government 145 94.8    0   0.0    8 5.2 153 0.650 2 0.701
Non-government 259 93.5    1   0.4    17 6.1 277
Variable Tobacco users have more friends Total χ2 df p-value
Agree   Can’t say Disagree
Gender
Male 183 83.9% 6 2.8% 29 13.3%   218   1.390 2 0.499
Female 171 80.7% 10 4.7% 31 14.6%   212
Type of school
Government 132 86.3% 2 1.3% 19 12.4%   153   4.570 2 0.102
Non-Government 222 80.1% 14 5.1% 41 14.8%   277

4. DISCUSSION

4.1. Socio-demographic Information

Most of the respondents (45.6%) were Janajati, followed by Brahmin/Chhetri, Dalit, and Muslim, which is similar to the findings of the study from Pokhara, Nepal [28]. Another study found that Janajati was six times higher than Brahmin/Chhetri, which was similar in this research [29]. In this study, a majority (97.0%) of the participants were aware of the harmful effects of tobacco. In a similar study conducted in Pokhara, a majority (93.6%) of participants were known about the harmful effects of tobacco [28]. The majority of the participants know about the harmful effects of tobacco because they might have studied tobacco consumption in the school curriculum. In this study, a majority of the participants were included from the nuclear family (53.5%), but the prevalence of tobacco consumption was significantly associated with the joint family (50%) defined by the p-value <0.001. In a similar study conducted in Dharan, the majority of the tobacco consumer was from a joint family (22.9%) [7]. In a joint family, there might be old-age people consuming tobacco, and children also follow them. In this study, most of the respondents (64.4%) were from government schools rather than non-government schools. However, tobacco consumption among respondents was higher in non-government schools (24.5%) than in government schools (19.6%). A similar study was conducted involving 89.6% of students from non-government schools [7]. One study conducted in Doula, Cameroon, showed that the prevalence of tobacco use among students was 10.6% and 11.3% from public and private schools, respectively [30].

This study showed a significant association between gender and tobacco consumption, which is similar to one of the study findings conducted in Nepal [7]. Male consumed more tobacco than females because males were more open to talking about tobacco consumption than females. This study showed the association of tobacco consumption with various factors. To reduce stress, they consumed tobacco either by smoking or chewing tobacco. In this study, students who have more pocket money were more likely to consume tobacco than students with less pocket money. Pocket money was significantly associated with tobacco consumption. Similarly, in the study from Kerala, there was a significant association between pocket money and tobacco consumption. Those who have more pocket money were four times more likely to consume tobacco than those with less pocket money [7, 29].

4.2. Prevalence of Tobacco Consumption

In this study, the prevalence of using tobacco among secondary-level students was found to be 22.8%. Similarly, in Nigeria, the prevalence of tobacco consumption was 22.0%, followed by Kerala (15.7%) [31]. Another study conducted in Dharan, Nepal, showed that the prevalence of tobacco consumption aged 16-26 was 24.8% which was nearly similar to this study [7]. The prevalence of tobacco consumption in this study was found to be higher than the other studies except for the study from Dharan, Nepal. One study conducted in the mountain area of Nepal showed that the overall prevalence of smoking was 73.7%, as the study was conducted in the mountain region, so cold might be influencing them to smoke [10].

4.3. Factors Associated with Tobacco Consumption

In this study, the age of the initiation to try cigarette smoking was 10 years old. Only 6.1% of participants consumed tobacco before the age of 10, but from the Global Youth Tobacco Surveillance (GYTS), 23.1% of adolescents consumed tobacco before the age of 10 years in Nepal. This might be because GYTS included all the young people, but in our study, only secondary level students were included; therefore, there was high consumption of tobacco before the age of 10 years. The mean age of tobacco initiation was 14.70, which was nearly similar to the study of Kathmandu (14.15), Noida (12.4), and Kerala (13.2). In this study, most of the participants consumed cigarettes (75.5%) and hookah (74.5%). In the study conducted in Birgunj, Nepal, cigarettes (70%) were the most common among the participants, which was similar to this study [1]. In this study, students consumed tobacco due to peer pressure (62.3%), which was found to be consistent with study findings from Bangladesh. In the study conducted in Dhaka, Bangladesh, and Birgunj, Nepal, students were found to be consuming tobacco due to the influence of friends (62.26%) and (48.8%), respectively [1, 32]. In this study, more than half of the tobacco consumers were influenced by tobacco advertisements. National Youth Tobacco Survey (NYTS) reported that 90% of participants were exposed to pro-tobacco advertisements [33]. In NYTS, a higher rate of participants was found to be influenced by pro-advertisements compared to this study; the reason behind this is that it included all the youth. In our study, television and radio were the main sources of information about tobacco consumption.

Students regularly exposed to SHS at home were more likely to consume tobacco than those who were non-exposer. Parents smoking in front of them might also influence them to adopt the habit of smoking. In this study, the prevalence of tobacco consumption is strongly significant among the participants exposed to SHS at home. The p-value was found to be < 0.0001, which was similar to the study of Pokhara and Kalaiya, Nepal. Students regularly exposed to SHS at public places were more likely to consume tobacco than those who were non-exposed. Exposure to SHS in a club and restaurants might influence them to adapt to the habit of smoking. Prevalence of tobacco consumption is strongly significant with the participants exposed to SHS at public places (p-value 0.000), which was also similar to the study from Pokhara and Kalaiya, Nepal [28, 29].

CONCLUSION

The prevalence of consumption of tobacco was higher in males as compared to female students. Type of family, gender, mother education status, occupation, pocket money, and education level were the major predictors of the prevalence of tobacco consumption among the students. Peer pressure and tobacco advertisements were major influencing factors associated with tobacco consumption. School-based education and intervention programs should focus on the vulnerable person to prevent tobacco use. Policy for the prohibition of smoking in public places, a ban on advertisements related to tobacco products, and smoke-free environments are highly recommended. It is also very necessary to provide knowledge among school students about the hazards of tobacco.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

Ethical approval was approved by the Institutional Review Board (IRB) of Pokhara University, Nepal (IRB Ref. No. 39/076/077). Permission was also taken from the concerned authorities of Syangja, Nepal, to conduct this study.

HUMAN AND ANIMAL RIGHTS

No animals were used in this research. All human research procedures followed were in accordance with the ethical standards of the committee responsible for human experimentation (institutional and national), and with the Helsinki Declaration of 1975, as revised in 2013.

CONSENT FOR PUBLICATION

The informed consent was taken, and confidentiality was maintained.

AVAILABILITY OF DATA AND MATERIALS

The study data and materials are not publicly available due to the confidentiality and privacy of the participants.

FUNDING

None.

CONFLICT OF INTEREST

The authors declare that they have no conflicts of interest.

ACKNOWLEDGEMENTS

Declared none.

REFERENCES

1
Chaudary A, Bhandari T. Prevalence of tobacco use and its associated factors among school going adolescents in birgunj sub-metropolitan, Nepal. JHAS 2016; 5: 72-6.
2
Global adults tobacco survey 2010. Available from: https://www.who.int/tobacco/surveillance/en_tfi_gats_turkey_2009.pdf?ua=1
3
Mbongwe B, Tapera R, Phaladze N, Lord A, Zetola NM. Predictors of smoking among primary and secondary school students in Botswana. PLoS One 2017; 12(4): e0175640.
4
Gurung A, Shrestha N, Silwal M, Gurung R, Ojha S. Prevalence of substance use and associated factors among high school adolescents in rithepani, lekhnath-2, kaski, Nepal. J Gandaki Med College 2017; 10(01)
5
Go MH, Green-HD JR, Kennedy DP, Pollard M, Tucker JS. Peer influence and selection effects on adolescent smoking. Drug Alcohol Depend 2010; 109(1-3): 239-42.
6
Chen L, Liu R, Pozhidaeva M, et al. Changes in the sociodemographic factors of tobacco and alcohol consumption in chinese adolescents from 2004 to 2011. Int J Environ Res Public Health 2018; 15(6): E1211.
7
Pradhan PMS, Niraula SR, Ghimire A, Singh SB, Pokharel PK. Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: A cross-sectional questionnaire survey. BMJ Open 2013; 3(2): e002123.
8
WHO global report on trends in prevalence of tobacco smoking 2015. World Health Organization; 2015. Available from: https://apps.who.int/iris/handle/10665/156262
9
Nazar GP, Chang KC, Srivastava S, Pearce N, Karan A, Millett C. Impact of India’s National Tobacco Control Programme on bidi and cigarette consumption: a difference-in-differences analysis. Tob Control 2020; 29(1): 103-10.
10
Jha N, Subba B. Prevalence of tobacco use among college students of Dharan, Eastern Nepal. Nepal J Sci Technol 2002; 4(1)
11
World Bank. Curbing the epidemic: governments and the economics of tobacco control. Tobacco Control 1999; 8(2): 196-201.
12
Khanal V, Adhikari M, Karki S. Social determinants of tobacco consumption among Nepalese men: findings from Nepal Demographic and Health Survey 2011. Harm Reduct J 2013; 10: 40.
13
Sunday K, Otavwe A, Imacualata N. Tobacco smoking and perceived effects among undergraduate students of novena university, ogume, Nigeria. J Biomed Pharm Sci 2018; 5(1): 24-30.
14
Gathuru IM, Tarter RE, Klein-Fedyshin M. Review of hookah tobacco smoking among college students: policy implications and research recommendations. Am J Drug Alcohol Abuse 2015; 41(4): 272-80.
15
Acharya SR, Pandey A. Place of delivery and newborn care practices in Kaski district: a cross sectional study from Nepal. J Biomed Sci 2014; 1(2): 6-11.
16
Banstola S, Acharya SR, Shin YC. Health problems among child labour in the brick industries of Nepal. Austin J Public Health Epidemiol 2019; 6(1): 1083.
17
Acharya SR, Shin YC, Moon DH. COVID-19 outbreak and suicides in Nepal: Urgency of immediate action. Int J Soc Psychiatry 2020.
18
Baral S, Moon DH, Shin YC, et al. Perception of food hygiene and nutritive value of the food. Korean Jour Food Health Convergence 2020; 6(4): 1-6.
19
Acharya SR, Poudel S. Factors associated with maternal and neonatal health care practices : A study from Nepal. Int J Health Sci Res 2020; 10(2): 186-92.
20
Acharya SR, Adhikari S, Pahari S, et al. Malnutrition and associated factors with nutritional status among orphan children: An evidence-based study from Nepal. Int J Child Health Nutr 2020; 9(3): 125-32.
21
Raj Acharya S, Kumar Ray A. Prevalence and root cause of uterine prolapse in Married Woman with Reproductive-Aged (MWRA) at VDC level in Nepal. Austin J Public Health Epidemiol 2017; 4(3): 1064.
22
Acharya SR. Utilization pattern of personal protective equipment’s among industrial workers of nawalparasi, Nepal. Health Prospect: J of Public Health 2014; 13(2): 24-7.
23
Bhattarai S, Subedi S, Acharya SR. Factors associated with early menarche among adolescents girls : A study from nepal. SM J Com Med 2018; 4(1): 1028.
24
Acharya SR, Bhatta J, Timilsina D. Factors associated with nutritional status of women of reproductive age group in rural, Nepal. Asian Pac J Health Sci 2017; 4: 19-24.
25
Kabir MA, Goh KL. Determinants of tobacco use among students aged 13–15 years in Nepal and Sri Lanka: Results from the global youth tobacco survey, 2007. Health Educ J 2013; 73(1): 51-61.
26
Sreeramareddy CT, Kishore P, Paudel J, Menezes RG. Prevalence and correlates of tobacco use amongst junior collegiates in twin cities of western Nepal: A cross-sectional, questionnaire-based survey. BMC Public Health 2008; 8: 97.
27
Sharma R, Grover VL, Chaturvedi S. Tobacco use among adolescent students and the influence of role models. Indian J Community Med 2010; 35(2): 272-5.
28
Paudel D. Tobacco use among adolescent students in secondary schools of Pokhara sub metropolitan city of Nepal. MPH thesis, Institute of Medicine, Nepal. 2003.
29
Bhaskar RK, Sah MN, Gaurav K, et al. Prevalence and correlates of tobacco use among adolescents in the schools of Kalaiya, Nepal: A cross-sectional questionnaire based study. Tob Induc Dis 2016; 14: 11.
30
Mbatchou Ngahane BH, Atangana Ekobo H, Kuaban C. Prevalence and determinants of cigarette smoking among college students: A cross-sectional study in Douala, Cameroon. Arch Public Health 2015; 73(1): 47.
31
Carroll Chapman SL, Wu LT. E-cigarette prevalence and correlates of use among adolescents versus adults: A review and comparison. J Psychiatr Res 2014; 54: 43-54.
32
Hossain S, Hossain S, Ahmed F, Islam R, Sikder T, Rahman A. Prevalence of tobacco smoking and factors associated with the initiation of smoking among university students in Dhaka, Bangladesh. Cent Asian J Glob Health 2017; 6(1): 244.
33
Bunnell RE, Agaku IT, Arrazola RA, et al. Intentions to smoke cigarettes among never-smoking US middle and high school electronic cigarette users: National Youth Tobacco Survey, 2011-2013. Nicotine Tob Res 2015; 17(2): 228-35.