Objective To assess the influence of smoking and tombak (local smokeless tobacco) dipping by parents, teachers and friends on cigarette smoking and tombak dipping by school-going Sudanese adolescents.
Methods This was a school-based cross-sectional survey was conducted in 2005–2006. Logistic regression was used for the analysis. A total of 4277 Sudanese school-going adolescents (aged 11–17 years) from 23 schools who completed an anonymous self-administered questionnaire on the use of tobacco products. Main outcome measures were self-reported tobacco use during the previous month defined current tobacco use. Ever smoking, tombak dipping and other tobacco products were also considered as outcomes.
Results After adjusting for sex, age and school grade, adolescents' smoking habits were strongly associated with the habit in their parents and friends and, more weakly, with tombak dipping by teachers. When adjusted for each other, the association with smoking in friends was unaffected and remained significant (prevalence OR (POR) of having ever smoked was 1.94, 95% CI 1.64 to 2.29; OR of being current smoker was 3.77, 95% CI 2.80 to 5.07). Tobacco smoking in friends was positively associated with adolescents ever tombak dipping (POR 1.81, 95% CI 1.41 to 2.33) and current dipping (OR 3.33, 95% CI 2.20 to 5.05). The association with parental habits was reduced but still significantly elevated. Tombak dipping by teachers was only associated with adolescents ever tobacco smoking.
Conclusions Tobacco use by parents, teachers and friends was associated with adolescents' tobacco habits. The influence of friends was the strongest. In developing programmes against adolescents' tobacco habits, there is need to target the influence of these ‘significant others’. Sudan needs to develop and implement comprehensive anti-smoking and anti-tombak dipping legislation to reduce the growing prevalence of such habits.
- tombak dipping
- smokeless tobacco products
- tobacco products
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- tombak dipping
- smokeless tobacco products
- tobacco products
Tobacco use is the foremost preventable cause of premature death worldwide.1 Currently, approximately 5.4 million people die each year due to tobacco-related illnesses. Unless current trends are changed, this figure is expected to increase to more than 8 million a year by 2030, and the vast majority are projected to occur in the developing world as the tobacco industry is steadily relocating to these countries due to tighter regulation in the developed world.1 2 Thousands of adolescents smoke their first cigarette and become daily smokers each day. Unfortunately, many of these adolescents will become addicted before they are old enough to understand the risks and life-threatening health consequences associated with tobacco use.3 This is a major challenge in Sudan, where the majority (41.7%) of the population is under 15 years (Sudan National Health policy, 2006). The current implementation of the WHO Framework Convention on Tobacco Control in Sudan is below expectation. There is also no official tobacco control policy specifically targeting adolescents in Sudan.
Parents may influence the likelihood that their child will smoke cigarettes through their own smoking behaviour.4 Having smoking friend(s) has been considered the most important factor influencing the habit in adolescents in the Western world.5 Moreover, the impact of parents is assumed to be more important for young children, while the impact of friends is believed to be more important for adolescents.6 The theory of planned behaviour suggests that approval of smoking by friends, parents and other key persons, for example teachers, is likely to increase the probability of smoking through the imitation of powerful role models.4
Unfortunately, among health-damaging habits, cigarette smoking and tombak (local smokeless tobacco) dipping are socially accepted behaviours among adults in Sudan. Cigarettes and tombak are cheap, openly advertised and sold in small shops on the streets. Most users dip tombak between the lower lip, vestibule and the gingivae. Epidemiological and laboratory studies have shown that the use of tombak is associated with increased risk of cancer of the oral cavity, and it is suspected to be associated with neoplasm of the salivary glands.7–9 In Sudan, little information exists on the prevalence and determinants of smoking and tombak dipping among adolescents. The prevalence estimate of tobacco smoking recorded from the 2001 Global Youth Tobacco Survey (GYTS) was 20%.10 No study has examined tombak dipping among adolescents in Sudan, or focused on the influence of teacher and parental tombak dipping on adolescent smoking and dipping behaviours. The present study was aimed at assessing the influence of smoking and tombak use by parents, teachers and friends on the use of tobacco among Sudanese adolescents in Khartoum State.
The present study was conducted within the framework of the Global Youth Tobacco Survey (GYTS) while the questionnaire was modified to the Sudanese context. The GYTS was initiated by the WHO, US Center for Disease Control and Prevention (CDC) and the Canadian Public Health Association to monitor tobacco use, attitudes about tobacco use and exposure to secondhand smoke among students aged 13–15 years. The goal of the GYTS is to enhance the capacity of countries to design, implement and evaluate their national comprehensive tobacco action plan.11 The Sudanese GYTS was carried out among school students, recruiting adolescents of grade 8 of basic and grades 1 and 2 of secondary schools. The school education system in Sudan comprises 8 years of basic education and 3 years of secondary education.
Sampling and subjects
A two-stage sampling technique was used to produce representative samples of students in grades associated with ages 13–15 years. At the first stage, primary sampling units were schools that were selected with probability proportional to the number of students that were enrolled in the specified grades. At the second stage, classes within the selected schools were obtained by random selection. All students in the selected classes were eligible to participate in the survey regardless of their age. In the sampling, weights were applied to effectively resize the sample so that it was representative of the population.
The survey targeted school-going adolescents throughout Khartoum State. The state was divided into seven areas, from which the schools were selected according to their enrolment sizes. The number of the schools and classes were different from area to area due to school size differences. We sampled 15 basic schools and 10 secondary schools. Two of the basic schools were closed at the time of the survey, hence were excluded. This gave a final number of 23 schools.
Permission to conduct the study was sought and obtained from the Ministry of Basic Education and from the superintendents and school authorities in Khartoum State. The principal of the selected schools or the contact persons and the representative persons from State Ministry of Health informed the students about the survey and obtained their consent, and confirmed that participation was voluntary and anonymous.
We retained the 56 questions from the GYTS questionnaire and added 12 new ones to address use of local tobacco products, namely tombak; the questionnaire was designed without skip patterns to allow all respondents to answer all questions.
The questionnaire was translated into Arabic and reverse translated into English to check for validity. Questions were formulated to suit local cultural sensitivity. The questionnaire underwent pilot testing among 120 subjects before implementation. Sudanese research coordinators trained the leaders of the field groups, who were responsible for data collection.
The survey was conducted in school year 2005–2006. The questionnaires were distributed to students attending classes and were completed during class time under the supervision of specifically trained research staff; teachers were not present. Completion lasted about 45 min. Since the questionnaires were anonymous, they were labelled before distribution with ID numbers identifying schools and classes.
Exposure and outcome measures
The questionnaire covered adolescents' personal characteristics (age, sex and school grades) tobacco habits (smoking and dipping tombak) of parents and friends, as well as tobacco use by teachers at school. The tobacco habits of parents, friends and teachers were assessed according to the adolescents' responses. Ever tobacco users include those who had tried to smoke cigarette or dipped tombak at any time in the past (even one or two puffs/dips). Current tobacco users represent those who had smoked/dipped tobacco products on 1 or more days in the preceding month of the survey. Other tobacco products include other tobacco products other than cigarette smoking.
Tombak is a locally made tobacco, always processed into a loose moist form, and its use is widespread in Sudan where it has been used for over three centuries. It is of the species Nicotiana rustica and the fermented ground powder is mixed with an aqueous solution of sodium bicarbonate. The resultant product is moist, with a strong aroma, and is highly addictive. It grows in silky or sandy soils in Northwest Sudan.12 It is very cheap in Sudan, about five times cheaper than cigarettes. Currently, tombak is sold in small plastic bags each containing about 100–150 g and one bag can be shared by 5–8 students in one sitting. It is also easy to hide the dip inside the mouth (‘suffa’), thereby making it easier to be used, and one packet can be shared among friends. In Sudan it is a common belief that tombak is less harmful to users than smoking; therefore smokers who quit cigarettes often become tombak users. Some of the questions on tombak included in the questionnaire were:
Have you ever tried or experimented with tombak, even one or two dips? (Yes/No)
During the past 30 days (1 month), on how many days you did you use tombak?
Do your parents use tombak? (None/Both/Father only/Mother only/I don't know)
Do any teachers use tombak inside the school? (Yes/No)
Data analysis was performed using SPSS V16.0 for Windows (SPSS, Chicago, Illinois, USA). The χ2 test was used to examine factors related to adolescents' behaviour (table 1). Logistic regression analysis was used to study the association between tobacco use by parents, teachers and friends (explanatory variables) and adolescents' tobacco use (outcome variables). Results from logistic regression analysis are presented as ORs with 95% CIs. Two adjusted models were created: in the first model, the association between each of explanatory variables was adjusted for adolescents' age, gender and school grade; in the second adjusted model, the tobacco habits of parents, friends and teachers were simultaneously included in the model containing adolescents' age, gender and grade at school.
Basic characteristics of the study population
The school response rate was 100%. The student response rate was 93%. Non-respondents were those absent from school the day of the survey. A total of 4277 questionnaires were collected; 41% were completed by girls, 53% by boys and 6% did not reveal their sex. The majority (66%) of the respondents were between 13–15 years. About 24% of the participants reported that they had ever smoked a cigarette and 7.5% described themselves as current smokers. Ever tombak users were 8.1%, 3.5% were current users and 12% stated that they use other tobacco products. About 17% of the respondents reported that at least one of their parents was currently smoking, while 14% said either of their parents was currently dipping. According to their reports, 41% of them said some or most of their friends were currently smoking, whereas 44% saw at least one of their teachers dipping tombak when at school. A higher prevalence of ever smoking, tombak dipping, current smoking and current dipping was seen among boys than girls (p<0.001). A higher prevalence of ever and current smoking was related to the secondary school grade (p<0.001), while higher prevalence of use of other tobacco products was seen among students in the basic grade (p<0.001). A higher prevalence of ever smoking, current smoking, ever and current tombak dipping and use of other tobacco products was seen among students whose either parents smoked. Similarly, students whose parents dipped were more likely to ever smoke and dip, and being current smoker and tombak dipper (p<0.001). Those whose friends were currently smoking and those whose teachers were dipping were more likely to engage in any of the tobacco habits (table 1).
Relation of the tobacco habits of parents, friends and teachers to adolescents' tobacco smoking
After simultaneously adjusting for the adolescents' age, gender, school grade and tobacco habits of parents, friends and teachers, the risk of adolescents to have ever smoked (prevalence OR (POR) 1.79, 95% CI 1.46 to 2.20), being current smokers (OR 1.67, 95% CI 1.22 to 2.27) increased with parental smoking. Parental tombak dipping was only associated with adolescents' ever and current smoking when adjusted for adolescents' age, gender and school grade but not when the tobacco habits of parents, friends and teachers were included into the model. Tobacco smoking by friends was positively associated with adolescents ever (POR 1.94, 95% CI 1.64 to 2.29) and current (OR 3.77, 95% CI 2.80 to 5.07) smoking. Tombak dipping by teachers was only associated with adolescents ever tobacco smoking (POR 1.50, CI 1.24 to 1.80) (table 2).
Relation of the tobacco habits of parents, friends and teachers to adolescents' tombak dipping and use of other tobacco products
Parental smoking was positively associated with adolescents' current tombak use in the model adjusted only for age, sex and grade at school, but not when the tobacco habits of parents, friends and teachers were included in the model (table 3). However, when the tobacco habits of parents, friends and teachers were simultaneously adjusted in the model; parental smoking was positively associated with adolescents' use of other tobacco products (POR 1.43, 95% CI 1.09 to 1.89). Parental tombak dipping was directly associated with adolescents' ever (POR 1.77, 95% CI 1.30 to 2.41) and current (OR 1.84, 95% CI 1.17 to 2.90) dipping. Tobacco smoking by friends was positively associated with adolescents' ever dipping (POR 1.81, 95% CI 1.41 to 2.33) and current dipping (OR 3.33, 95% CI 2.20 to 5.05) (table 3).
This survey, the first ever of its kind in this area, provides information on the current prevalence of tobacco smoking, tombak dipping and use of other tobacco products in Sudanese adolescents, and the influence of the tobacco habits of parents, friends and teachers on adolescents' tobacco use behaviours. The results show that the tobacco habits of parents and friends influenced adolescents' tobacco use more than that of their teachers. Importantly, our observations indicate that tobacco smoking by these ‘significant others’ may influence adolescents' tobacco smoking and also increase their risk of use of smokeless tobacco.
Strengths of the study are the large sample size, random selection of subjects and a high participation rate. The results can be regarded as representative of the population of Khartoum State and, because of its multiethnic composition, our estimates may be generalised to most parts of the country, particularly the Central, Eastern and Northern states, but less so to the states in the Southern and Western areas of the country. A second potential limitation of this study is that current adolescent tobacco use and that of their parents was obtained by respondent recall, which is subject to bias and deliberate misreporting. We implemented all standard means to minimise these potential biases: we undertook a pilot study, through which we reworded and revised the contents of the questionnaire aimed at achieving a more reliable and valid response. Furthermore, the failure to include questions to assess the smoking habits of teachers (only tombak dipping was measured) and tombak dipping by friends (only smoking was measured) made us unable to examine the influence of these factors on adolescents' tobacco behaviour. However, considering the strength and direction of the influence of parental smoking and tombak use on adolescents' tobacco use, we believe similar results would have been obtained if we had studied the effects of smoking by teachers and tombak dipping by friends on adolescents' tobacco habits. Finally, the lack of information concerning the socioeconomic status of the participants, such as parental education and income did not allow us to adjust for the effects of these potential confounders. Thus residual confounding by these unmeasured variables may influence our results.
The prevalence of smoking among Sudanese adolescents in this study (24%) was greater than the prevalence measured in 2001 in a previous GYTS (20%),10 suggesting increasing trends. Compared with other sub-Saharan African countries, the current prevalence of smoking among Sudanese adolescents ranks among the highest recorded in the same period: 18% in Uganda-Kampala, 10% in Ethiopia, 14% in Ghana, 19% in Nigeria, 9% in Malawi and 15% in Kenya.13 The prevalence of adolescents' smoking was also high when compared to the nearest countries in the Eastern Mediterranean region, where the prevalence was 14% in Egypt and 15% in Libya; a greater prevalence was reported only in Saudi Arabia.10
Our results indicate that school-going adolescents' tobacco behaviour was influenced mainly by friends tobacco use and that of their parents, and less so by that of their teachers. When parental influence is compared to that of the friends, the risk estimates from our results show that the influence of friends was stronger. These observations are in agreement with a study from the US, which showed that the influence of friends on adolescents' tobacco use was stronger than that of the parents.5 In contrast, a Taiwanese study showed that the influence of the parents was stronger than that of friends, when parental tobacco habits were considered.14 In a study from Malawi, it was reported that having at least one parent smoker or a friend who was a smoker was strongly associated with increased tobacco use by the adolescent.15 In general, the influence of friends is considered the most important predictor of adolescent tobacco use compared to that of the parents.16 Children usually imitate their parents from their early childhood,17 while the influence of friends may be more important when they grow into their teens.6 According to the theory of planned behaviour, approval of smoking by friends, parents and other key persons, for example teachers, is likely to increase the probability of smoking, through the imitation of these role models.4
Although the influence of teacher tobacco behaviours was less prominent than that of the parents and friends, we also observed a direct influence of the tobacco habits of teachers on that of their students, so that when the teacher dips inside the school buildings, the students are more likely to try smoking. Almost half of the smoking students reported that they had seen some of their teachers dip inside their school buildings. A study from the UK, conducted among 6000 students aged 11–12 years suggested that a higher proportion of student smokers was found in schools having a higher proportion of smokers among the teaching staff.18 Similar findings were reported in a study conducted in Denmark among students aged 15–16 years old, in which 57% of the students reported that they were exposed to teachers smoking in the staff room.19
An important observation from the present study, which has not been well reported previously, is that tobacco smoking by parents and friends influenced adolescents' smoking and also increased the risk of tombak dipping and the use of other tobacco products, respectively. In addition, tombak dipping by teachers increased the risk of adolescents' tobacco smoking. Although the reason for these observations is not clear in the present study, a Swedish study with similar findings suggested that the contextual social norms related to tobacco habits may explain the observed influence of tobacco smoking in significant others on the use or initiation of smokeless tobacco, or vice versa.20 Our results indicate that the influence of tobacco smoking may extend to the use of other tobacco products as well. Therefore, it would be useful to more carefully examine this proposition in subsequent studies.
The influence of friends may be difficult to ascertain accurately,21 considering that smokers may be prone to select other smoking friends, thus may report the habits of smoking friends more than non-smoking friends. Such selection might likely have produced the association observed in our study between friends and adolescents' tobacco use.22 23 However, some students do not like to reflect the behaviours of their parents regarding tobacco use, and may be more prone to blame their friends or their teachers regarding their tobacco attitudes, which may mask the real situation at home. Several studies have shown that smoking adolescents actively seek out groups of friends with similar smoking behaviours, and student smokers are more likely to be aware of others who smoke.22 24 Dippers may also be more likely to be aware of others who dip tombak.
Compared with Sudanese GYTS survey in 2001, our study shows that tobacco smoking and use of related products among school-going adolescents is increasing. The study also demonstrates that the tobacco habits of parents, friends and teachers are important predictors of adolescents' tobacco use, although the influence of the friends and parents were the most prominent. In developing programmes against tobacco use by adolescents, there is the need to target the habits of parents, teachers and peers as important influencing factors. This could be achieved by establishing a school-based tobacco policy that targets students and teachers, including anti-tobacco use syllabus as part of the school curriculum and including parents as part health promotion among adolescents. Furthermore, comprehensive efforts focusing on anti-smoking and anti-tombak dipping legislation need to be developed and implemented in Sudan considering their rising prevalence among adolescents.
What this paper adds
This study provides the first assessment of tombak (local smokeless tobacco) dipping among Sudanese school-going adolescents, and showed that tobacco use by friends and parents were the most important influencing factors on adolescents' tobacco use, while tobacco use by the teachers played a minor role.
The study also shows that tobacco smoking by parents and friends influenced adolescents' smoking and also increased the risk of tombak dipping and the use of other tobacco products, whereas tombak dipping by teachers increased the risk of adolescent tobacco smoking.
The study points to the need to target these ‘significant others’ when planning tobacco prevention and intervention programmes among adolescents.
The collection of this data was supported financially by the WHO and Center for Disease Control and Prevention (CDC), USA. We thank the Sudan Ministry of Basic Education for the permission and support given for the conduct of this survey. We are also grateful to the Federal and Khartoum State Ministry of Health, who contributed to the successful implementation of the fieldwork of this study. We also thank directors and students of the schools that participated in the study. We are grateful to Dr Charles W Warren (CDC), Dr Fatima Alawa (WHO, EMRO Region), Dr Abdel Gadir and Dr Mona Mustafa (Research Directorate, Khartoum) for their support and expertise.
Funding The collection of this data was supported financially by the World Health Organization and Center for Disease Control and Prevention (CDC), USA.
Competing interests None.
Ethics approval This study was conducted with the approval of the Federal and Khartoum State Ministries of Health.
Provenance and peer review Not commissioned; externally peer reviewed.
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