ORIGINAL RESEARCH

https://doi.org/10.5005/jp-journals-10077-3306
Journal of South Asian Association of Pediatric Dentistry
Volume 7 | Issue 2 | Year 2024

Implementation Status of Tobacco-free Education Institutional Guidelines at Schools in Rural Areas of District Saharanpur, Uttar Pradesh

Sanjeev K Singh¹, Mohit Wadhawan², Amit M Varshney³, Amit Kumar⁴

^1,2Department of Dentistry, Shaikh-Ul-Hind Maulana Mahmood Hasan Medical College, Saharanpur, Uttar Pradesh, India

³Department of Community Medicine, Shaikh-Ul-Hind Maulana Mahmood Hasan Medical College, Saharanpur, Uttar Pradesh, India

⁴Department of Oral Health Sciences, Santosh Dental College and Hospital, Ghaziabad, Uttar Pradesh, India

Corresponding Author: Sanjeev K Singh, Department of Dentistry, Shaikh-Ul-Hind Maulana Mahmood Hasan Medical College, Saharanpur, Uttar Pradesh, India, Phone: +91 9780554348, e-mail: san.bajaj88@gmail.com

Received: 20 April 2024; Accepted: 30 May 2024; Published on: 06 September 2024

ABSTRACT

Background: The tobacco-free educational institution (ToFEI) guidelines by the Government of India (GOI) can be used by schools as a self-evaluation scorecard to assess the implementation status of these guidelines.

Aim: This observational study assessed the school’s adherence to the ToEFI guidelines in the district of Saharanpur, Uttar Pradesh, India.

Materials and methods: Around 102 schools (62 government and 40 private) were conveniently selected in a block. None of the schools fulfilled the criteria of mandatory scores. The government schools (32.87 ± 20.97) scored significantly more than private schools (20.45 ± 13.31) for overall ToFEI scores (p = 0.001). The mean mandatory ToFEI scores observed in the government and private schools were 18.71 ± 14.87 and 9.0 ± 7.08, respectively (p = 0.001). None of the schools have marked a 100-yard area from the outer limit of the boundary wall/fence of the educational institute.

Conclusion: The mean ToFEI scores were very low among the schools included (28.0 ± 19.27). The alarming situation calls for integrating the ToFEI agenda into regular school-based programs and assisting schools in attaining a tobacco-free status.

Keywords: Cigarette and other tobacco product act, Children, School, Tobacco-free educational institution, Tobacco-free schools

How to cite this article: Singh SK, Wadhawan M, Varshney AM, et al. Implementation Status of Tobacco-free Education Institutional Guidelines at Schools in Rural Areas of District Saharanpur, Uttar Pradesh. J South Asian Assoc Pediatr Dent 2024;7(2):94–98.

Source of support: Nil

Conflict of interest: None

INTRODUCTION

Tobacco use is a grave concern globally and in India specifically, given the high prevalence rates across different age-groups. The impact of tobacco is not just limited to the users. Secondhand smoke poses notable health hazards to nonsmokers, especially children and infants, who are more vulnerable to its harmful effects. The statistics from the Global Adult Tobacco Survey (GATS) and the Global Youth Tobacco Survey (GYTS) highlight the need for targeted interventions, as 28.6% of adults aged 15 years and 14.6% of children aged 13–15 years in India use tobacco in some form.¹^,³ Efforts to educate and dissuade younger populations from taking up smoking or using tobacco are particularly crucial in preventing future health issues.

While the Government of India (GOI) has indeed made commendable efforts by enacting the Cigarette and Other Tobacco Products Act (COTPA) in 2003 and launching the National Tobacco Control Program (NTCP) in 2007–2008, the effectiveness of these measures depends significantly on their proper implementation and enforcement.⁴^,⁵ The prohibition of smokeless tobacco products through the Food Safety and Standards (prohibition and restrictions on sales) Regulation, 2011, is a positive step toward addressing the diverse forms of tobacco consumption. However, the persistent issue lies in the weak enforcement of these laws and regulations. This lack of proper implementation allows tobacco use to continue, contributing to the ongoing public health challenge. The guidelines for tobacco-free educational institution (ToFEI) under NTCP are crucial for creating environments that discourage tobacco use, especially among the younger population.⁶^,⁷

Studying adherence to tobacco-free educational area policies is crucial for understanding the effectiveness of such measures in rural or urban settings. The studies by Kumar et al. and Chatterjee et al. likely provide insights into the challenges and successes of implementing tobacco-free policies in schools in India.⁸^,⁹

Addressing the social environment in schools, including the smoking habits of teachers, is a holistic approach to tobacco control. It involves creating supportive policies, fostering a culture of tobacco-free environments, and providing resources for cessation.¹⁰ Hence, this study aims to assess the adherence of private and government schools to tobacco control policies, which is essential for understanding the effectiveness of these measures in different types of educational institutions.

MATERIALS AND METHODS

The Department of Dentistry, Shaikh-Ul-Hind Maulana Mahmood Hasan Medical College, Saharanpur, Uttar Pradesh, India, conducted this cross-sectional study. Ethical clearance and permission were obtained from the Institutional Ethics Committee (62/08112/2023) and the Department of School Education (15,100-04/2022-23/20/01/2023) in Saharanpur.

Sample Selection

There are 11 blocks in Saharanpur, of which one block was randomly selected. In this block, data were obtained from 102 schools, which included 62 government and 40 private schools.

Assessment of Adherence to Tobacco-free Educational Institution Guidelines

This study used a standard nine-criteria checklist of ToFEI guidelines by NTCP, GOI. The first three criteria, including their subcriteria, are mandatory for all institutions/schools. All nine questions of these criteria have some weightage points; the first three criteria and their subcriteria have 10 weightage points. Criteria from 4 to 7 have nine weightage points, and the last two standards have a weightage of seven points each. The total score for these nine-question criteria is 100.

Data Collection and Analysis

Investigators were trained and calibrated in the pilot phase before data collection. The investigators collected the data during working days after obtaining permission. The study’s objective was explained to the school’s principal, and after that, the investigator collected the data using an observational checklist. Tobacco sales within 100 yards of the school premises were observed covertly, and photographs were taken. The presence of a copy of COTPA by school authorities and the existence of anti-tobacco messages on school stationery were noted.

Statistical Analysis

Statistical analyses were performed using Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics for Windows, Version 25.0; Armonk, New York: IBM Corp). Results on continuous measurement are presented as mean ± standard deviation (SD) and categorical data as frequency (percentage). A comparison between the groups was made using the Mann–Whitney U test. A p-value < 0.05 was considered statistically significant.

RESULTS

The cross-sectional study was carried out on 102 schools in one block of the district of Uttar Pradesh, which comprised 62 government schools and 40 private schools. Adherence to the ToFEI guidelines consists of nine points, and the distribution between the government and private schools is presented in Table 1.

**Table 1:** Comparison of ToFEI score between government and private schools
Criteria (weightage points)	Government (n = 62) n (%)	Private (n = 40) n (%)	Total (N = 102) n (%)
Display of “tobacco-free area” signage inside the premises of the Educational Institute at all prominent place(s) (mandatory 10)	28 (45.16)	2 (5)	30 (29.41)
The name/designation/contact number is mentioned/updated in the signage (mandatory 10)	10 (16.13)	0	10 (9.80)
Display of “tobacco-free education institution” signage at entrance/boundary wall of educational institute (mandatory 10)	20 (32.26)	4 (10)	24 (23.53)
The name/designation/contact number is mentioned/updated in the signage (mandatory 10)	10 (16.13)	2 (5)	12 (11.76)
No evidence of the use of tobacco products inside the premise, that is, cigarette/beedi butts or discarded gutka/tobacco pouches, spitting spots (mandatory 10)	48 (77.42)	28 (70)	76 (74.51)
Poster or other awareness materials on the harms of tobacco displayed in the premise (9)	24 (38.71)	6 (15)	30 (29.41)
Organization of at least one tobacco control activity during the past 6 months (9)	14 (22.58)	14 (35)	28 (27.45)
The designation of tobacco monitors and their names, designations, and contact numbers are mentioned on the signage (9)	10 (16.13)	4 (10)	14 (13.73)
Inclusion of the “no tobacco use” norm in the educational institute’s code of conduct guidelines (9)	6 (9.68)	2 (5)	8 (7.84)
Marking of 100 yards area from the outer limit of the boundary wall/fence of the educational institute (7)	0	0	0
No shops selling tobacco products within 100 yards of the educational institute (7)	56 (90.32)	32 (80)	88 (86.27)

Table 2 shows a ToEFI score comparison between the government and private schools, which shows that the government schools’ scores are significantly better in displaying tobacco-free area signages inside the school premises and in mentioning designated names and persons in all the prominent places. Some schools also showed the “tobacco-free education institution” signage at the entrance/boundary wall. Most government school principals have an idea about the ToFEI guidelines and have been informed by the education department that some renovation works are being carried out, so most of them still need to show posters or other awareness programs about tobacco.

**Table 2:** Comparison of ToFEI score between government and private schools
Criteria (weightage points)	Government (N = 62)	Private (N = 40)	Total	p-value
Display of “tobacco-free area” signage inside the premises of the educational institute at all prominent place(s) (mandatory 10)	4.52 ± 5.01	0.50 ± 2.20	2.94 ± 4.57	0.001*
The name/designation/contact number is mentioned/updated in the signage (mandatory 10)	1.613 ± 3.71	0.00 ± 0.00	0.98 ± 2.98	0.008*
Display of “tobacco-free education institution” signage at entrance/boundary wall of educational institute (mandatory 10)	3.23 ± 4.71	1.00 ± 3.04	2.35 ± 4.26	0.010*
The name/designation/contact number is mentioned/updated in the signage (mandatory 10)	1.61 ± 3.71	0.50 ± 2.21	1.17 ± 3.24	0.090
No evidence of the use of tobacco products inside the premise, that is, cigarette/beedi butts or discarded gutka/tobacco pouches, spitting spots (mandatory 10)	7.74 ± 4.21	7.00 ± 4.64	7.45 ± 4.37	0.404
Poster or other awareness materials on the harms of tobacco displayed in the premise (9)	3.48 ± 4.43	1.35 ± 3.25	2.64 ± 4.12	0.011*
Organization of at least one tobacco control activity during the past 6 months (9)	2.03 ± 3.79	3.15 ± 4.34	2.47 ± 4.03	0.172
The designation of tobacco monitors and their names, designations, and contact numbers are mentioned on the signage (9)	1.45 ± 3.33	0.90 ± 2.73	1.24 ± 3.11	0.382
Inclusion of the “no tobacco use” norm in the educational institute’s code of conduct guidelines (9)	0.87 ± 2.68	0.45 ± 1.98	0.71 ± 2.43	0.393
Marking of 100 yards area from the outer limit of the boundary wall/fence of the educational institute (7)	0.00 ± 0.0	0.00 ± 0.00	0.00 ± 0.00	1.00
No shops selling tobacco products within 100 yards of the educational institute (7)	6.32 ± 2.08	5.60 ± 2.84	6.04 ± 2.42	0.141
Total	32.87 ± 20.97	20.45 ± 13.31	28.0 ± 19.27	0.001*

*, statistically significant

The mandatory score that each school should achieve is 50. The mean mandatory scores observed in the government and private schools were 18.71 ± 14.87 and 9.0 ± 7.08, respectively (Table 3). However, the difference is statistically significant (p = 0.001). For the mandatory scores, government schools have better adherence or compliance with the guidelines compared to private schools. None of the schools has marked a 100-yard area from the outer limit of the boundary wall/fence of the schools. However, many rural schools were surrounded by fields,

**Table 3:** Tobacco-free educational institution mandatory score comparison between government and private schools
	Government (N = 62)	Private (N = 40)	Total	p-value
Mandatory score (maximum = 50)	18.71 ± 14.87	9.0 ± 7.08	14.90 ± 13.25	0.001*

*, statistically significant

DISCUSSION

The emphasis on a smoke-free environment in educational institutions is critical for protecting students from the hazards of tobacco use and secondhand exposure. The challenges posed by aggressive tobacco promotion and the issue of tobacco waste on campuses highlight the importance of stringent measures to counteract these influences. The present study intends to measure the implementation status of ToEFI guidelines and highlights that the mean ToFEI scores were very low among the schools included (28.0 ± 19.27).

For the guidelines framed for schools, it was recommended that the schools assess the adherence to the implementation of these guidelines every year and get a certificate to this effect for those who have scored >90%. Once schools or institutions determine they have met the benchmark score, they may opt to enroll in the ToFEI award scheme.⁶ Upon validation, a ToFEI certificate will be granted if the school surpasses the benchmark. The specifics of the ToFEI award scheme will be provided separately by the GOI.⁶

Few studies have been conducted in India, and a widespread violation of section 6 of the COTPA 2003 in Delhi, Mumbai, and Bengaluru has been reported, primarily due to unrestricted access to the outlets.¹¹^,¹³ The findings suggest that despite the existence of regulations, there are challenges in enforcing them effectively, leading to widespread violations. This underscores the importance of addressing issues related to the accessibility of tobacco products.

The statistics indicate a low prevalence of signage in schools in Chennai concerning restrictions on tobacco product sales and smoking prohibition.¹⁴ Expressly, signage displayed by 0.7% of schools indicated a complete restriction on tobacco sales, and a slightly higher percentage, 2.8%, had smoking prohibition signage.¹⁴ These figures highlight a potential gap in awareness or enforcement of regulations. Clear signage can be crucial in informing students, staff, and visitors about the rules in place and creating a tobacco-free environment.

In Raipur Rani, Haryana’s urban and rural areas, the implementation status of ToFEI guidelines was not concordant with the present study.⁸ It is positive to note that according to Ruhil, there was a reported decrease in tobacco usage among 13–15-year-old children in urban areas. The study attributes this positive trend to increased compliance with ToFEI guidelines. Implementing and adhering to specific guidelines, possibly related to creating tobacco-free environments, maybe a practical step in reducing tobacco usage among adolescents.¹⁵

Publications and research studies from the United States of America often highlight the success stories associated with these policies, showing correlations between the execution of tobacco-free school policies and the decline in smoking rates among young individuals.¹⁶^,¹⁸ There is evidence that isolated classroom instruction could be more effective. Various methods are essential to effective school-based prevention programs, like positive role models, cessation support, and community programs with the active involvement of parents, mass media, community organizations, etc.¹⁹

Most of the Indian studies have focused on the prevalence of smoking among adolescents.²⁰^,²¹ Besides prevalence, prevention and control of its consumption through various education and smoking cessation programs have also been studied.²²^,²³ Several studies have investigated compliance with the COTPA regulation, which prohibits the use and sale of tobacco.²⁴^,²⁵ These studies collectively contribute to a better understanding of the smoking landscape among adolescents in India and the effectiveness of various strategies in curbing tobacco use. The emphasis on regulation compliance suggests an awareness of the need for legal measures to support broader anti-smoking initiatives.

The study conducted by Selvavinayagam focused on investigating the implementation of seven of their 11 tobacco-free standards in educational institutions in Tamil Nadu.²⁶ The researchers took a proactive approach by designing 2,000 educational institutions to be tobacco-free. Specific standards suggest a comprehensive framework to ensure these institutions adhere to guidelines promoting a tobacco-free environment.

Schools facilitated student participation in various extracurricular activities, providing development workshops for staff and other advanced facilities or activities to promote the achievement of positive social norms and encourage youth to connect with their school.²⁷ The use of e-cigarettes, particularly among young people, is increasing in many countries, with the use of e-cigarettes and conventional cigarettes being common.²⁸ Students are less likely to feel connected to school when they use substances or engage in violent activity at an early age.²⁹ Schools that provide opportunities for holistic development for students and staff appear more likely to implement smoke-free policies. Incorporating tobacco control programs into overall school development goals is the way forward. These initiatives reflect a holistic approach to education, recognizing that various factors inside and outside the classroom influence student well-being and engagement.

Schools that do not participate in athletics or extracurricular competitions, especially during budget cuts, may be skeptical about the effectiveness of such activities and evaluate them in terms of academic performance; implementing tobacco prevention and control programs in schools represents an additional burden of little value to the overall goal of academic success.³⁰ Ultimately, balancing academic priorities and holistic student development is crucial.

The recent review highlights the importance of considering the school context and implementation methods to assess the effects of guidelines on adolescents’ cognitions and behaviors.³¹^,³² Varying enforcement of these policies by school staff can have implications for adolescents’ attitudes and beliefs about smoking.³²^,³³ In summary, for effective implementation of these guidelines, attention needs to be given to developing policies, and their consistent implementation within the school context can contribute to a more comprehensive and impactful approach to tobacco control in schools. Even online platforms like Google advertisements, Facebook, Twitter, Snapchat, and Instagram should have strict approaches against utilizing their stages to promote tobacco and vape/electronic cigarette items. The limitation of the present study is that it needs to assess the various factors that create hurdles in implementing or adhering to these guidelines, and the sample size also limits its generalizability.

The findings from the present study highlight significant points regarding implementing tobacco-free policies in schools.

Government schools outperformed private schools in the ToFEI score. This unexpected result could serve as a basis for further investigation into the factors contributing to government schools’ better performance.
None of the schools in the study achieved ToFEI status. It indicates a potential gap in implementing tobacco control measures in government and private schools.
The study underscores the need for support for principals and school teachers in meeting challenging standards related to tobacco control.
The recommendation to train designated school principals and teachers as tobacco control leaders recognizes educators’ influential role in shaping school culture.
The study suggests linking tobacco control efforts to general school development goals. This integration can help prioritize tobacco control measures as an integral part of the school’s overall improvement strategy.
Policymakers and implementers are encouraged to view the ToFEI guidelines as a routine part of school-based programs. It involves ongoing support for schools in achieving and maintaining tobacco-free status.

In conclusion, the present study’s findings emphasize the standing of collaborative efforts, training, and policy integration to enhance the implementation of tobacco control measures in schools. By providing the necessary support and recognizing the role of school leaders, there is potential for creating healthier and tobacco-free educational environments.

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