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Implementation of the Uttarakhand Tobacco Free Initiative in Schools, India, 2016

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Implementation of the Uttarakhand Tobacco Free Initiative in Schools, India, 2016 PREVENTING CHRONIC DISEASE PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY Volume 18, E74 JULY 2021 IMPLEMENTATION EVALUATION Implementation of the Uttarakhand Tobacco Free Initiative in Schools, India, 2016 Isabel Garcia de Quevedo, MSPH1; Rene A. Arrazola, MPH2; Rajesh Yadav, MBBS, MSPH3; Biesse D. Soura, PhD, MA2; Indu B Ahluwalia, PhD2 Accessible Version: www.cdc.gov/pcd/issues/2021/20_0650.htm bacco use and secondhand smoke, 2) encourage participation in student-led activities to promote tobacco-free initiatives, and 3) Suggested citation for this article: Garcia de Quevedo I, enforce tobacco-free school policies in the state of Uttarakhand. Arrazola RA, Yadav R, Soura BD, Ahluwalia IB. Implementation of the Uttarakhand Tobacco Free Initiative in Schools, India, Evaluation Methods 2016. Prev Chronic Dis 2021;18:200650. DOI: https://doi.org/ We used the CDC evaluation framework to document key com- 10.5888/pcd18.200650. ponents and lessons learned from the UTFI. We distributed ques- tionnaires to 71 teachers and principals in December 2016, to as- PEER REVIEWED sess awareness of school activities and policies related to the initi- ative. Descriptive statistics were computed for quantitative data, and a thematic content analysis was used for qualitative data. Summary What is already known on this topic? Results Tobacco use in India is responsible for 1 million deaths each year. Imple- mentation of school-based interventions may reduce student and teacher Of the 71 participants, 66 (92.9%) were aware of tobacco use tobacco use, as part of a comprehensive approach to tobacco prevention policies in schools, and 63 (88.7%) agreed policies were enforced. and control. Sixty-six participants (93.0%) said that they taught tobacco What is added by this report? prevention-related topics, and 41 of 70 respondents (58.6%) repor- Our evaluation provides lessons learned from implementation of the Ut- ted that a student-led group helped to enforce tobacco-free policies tarakhand Tobacco Free Initiative (UTFI), a school-based intervention in in their schools. Of 69 respondents, almost all (n = 66) reported the state of Uttarakhand, India, to raise awareness, educate, and enforce school policies among public schools in the state. satisfaction with UTFI implementation. Challenges identified were What are the implications for public health practice? related to tobacco products being readily accessible near school Our process evaluation provides information for school administrators to premises, lack of tobacco prevention materials, and tobacco use by improve UTFI delivery and might serve as a model for other tobacco con- school staff. trol partners who want to implement similar school-based interventions. Implications for Public Health Successes of UTFI were documented by measuring different com- Abstract ponents of the process, including implementation of program activities and teacher and principal satisfaction. Results might help Purpose and Objectives enhance key processes for the initiative and highlight some barri- A process evaluation, the Uttarakhand Tobacco Free Initiative ers to implementation, such as enforcing tobacco control policy (UTFI), was conducted in 49 public high schools and colleges in off school premises. Continued efforts are needed to prevent to- the state of Uttarakhand, India, to measure program implementa- bacco use among young people. tion, provide feedback to school administrators, and identify barri- ers to tobacco control. Introduction Intervention Approach Tobacco use, the leading cause of preventable death, results in UTFI aims to 1) raise awareness and provide education and tools more than 8 million deaths worldwide each year, including 1.2 for teachers and school administrators about the dangers of to- million nonsmokers who are exposed to secondhand smoke (1). In The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. www.cdc.gov/pcd/issues/2021/20_0650.htm • Centers for Disease Control and Prevention 1 This publication is in the public domain and is therefore without copyright. All text from this work may be reprinted freely. Use of these materials should be properly cited. PREVENTING CHRONIC DISEASE VOLUME 18, E74 PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY JULY 2021 India alone, tobacco use is responsible for about 1 million deaths Uttarakhand Tobacco Free Initiative (UTFI) to protect the state’s each year (2,3). India’s most recent data on tobacco use shows that young people from tobacco products. UTFI implementation began prevalence among Indian students was 14.6% in 2009 (4). In Ut- in 2011 throughout all government high schools and colleges, tarakhand, the prevalence of current tobacco use among students Government Inter-Colleges, and Government Girls Inter-Colleges. in grades 8 through12 was 12.2% in 2013 (20.8% boys and 0.3% The objective of UTFI is to raise public awareness about the girls) and 7.4% in 2016 (12.9% boys and 0.8% girls) (5,6). dangers of tobacco products through education, communication, and training in schools. The aim of our cross-sectional evaluation As part of a comprehensive approach to tobacco prevention and was to assess key processes and measures related to UTFI, includ- control, schools are settings where programs can be implemented ing 1) awareness among principals and teachers of the initiative to prevent young people from starting tobacco use (7,8). The US and the activities implemented, 2) access to resources, 3) satisfac- Surgeon General’s Report, Preventing Tobacco Use Among Youth tion with the initiative, 4) awareness of tobacco prohibitions in and Young Adults, concluded that multicomponent interventions schools, and 5) barriers to implementation. Data for the evalu- that combine school-based interventions with mass media cam- ation were collected simultaneously with the Uttarakhand Youth paigns, tobacco price increases, and community-wide changes in Tobacco Survey (UYTS), from December 10 through December smoke-free policies are effective in reducing the initiation, preval- 31, 2016. ence, and intensity of smoking among young people (9). Some school-based tobacco prevention and control interventions Intervention Approach have been successful in low-income, transitional, and high-income UTFI required all government schools in the state to include the countries (8,10–14). These interventions have shown to be effect- following 3 components in their programs: ive for young people when they include social influence models, peer support, and a duration of more than 1 year (9). The greatest Awareness and education. Delivery of tobacco control messages in school impact is achieved by a multipronged approach that includes a be- and at home, distribution of tobacco education materials, and training of havioral component, policy and environmental approaches, mass teacher−champions (selected teachers) to implement tobacco prevention media campaigns, and community-wide elements (9,10). In India, and cessation activities. some studies that evaluated the effect of school-based tobacco in- Peer-led activities. Creation of a student-led anti-tobacco brigade (peer-led terventions demonstrated positive results (13,14). A multicompon- group) to disseminate tobacco control and prevention messages and to ent school-based intervention that included tobacco education, ad- monitor that school tobacco-use prohibition is enforced. vocacy, peer support, and parental involvement showed that stu- School policy. Prohibition of tobacco use on school premises for all teachers, dents in the intervention group were less likely than those in the employees, and students and ensuring closure of outlets selling tobacco control group to smoke cigarettes or bidis during the 2-year study products within 100 yards of educational institutions. (15). (Bidis are small tobacco-filled leaf wraps made primarily in Southeast Asia.) Other school programs in India that focused on increasing awareness of tobacco’s harmful effects and enhancing UTFI reached 332,634 students in 1,266 public high schools and life and advocacy skills among students and school staff reduced colleges in all 13 districts of Uttarakhand. We conducted a pro- tobacco use among students (14,16). cess evaluation of UTFI by collecting cross-sectional feedback from teachers and school principals. Purpose and Objectives Evaluation Methods In 2004, India ratified the World Health Organization Framework Convention on Tobacco Control. Since then, the country has been Our evaluation included principals and teacher−champions from making strides in decreasing tobacco use in the general popula- 50 schools that participated in UYTS 2016 (5) who were also im- tion. India’s national comprehensive tobacco control law, The Ci- plementing UTFI. One school, which was not a part of the Ut- garettes and Other Tobacco Products Act, 2003 (COTPA), covers tarakhand public school system, was excluded, leaving 49 schools several topics, including protecting young people by prohibiting for analysis. Non–tobacco-consuming teachers, nominated by the smoking in public places, prohibiting the sale of tobacco products schools, were assigned as teacher–champions. These teachers to minors, prohibiting all sales of tobacco products near education- worked with other teachers and students to implement tobacco al institutions, and strong pictorial health warnings
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