Which school-based model produces adolescent advocates for tobacco prevention in rural Maharashtra? A quasi-experimental study

INTRODUCTION

India bears a heavy burden of non-communicable diseases (NCDs) and their risk factors. Tobacco use alone accounts for roughly 27 % of all cancers in the country, causing about one million preventable deaths each year.^1,2 Unhealthy behaviours continue to increase the incidence of diabetes, cardiovascular disease, dementia and cancer. India currently has 23% of the world’s diabetes cases and the third-highest share of people with obesity. The present estimate of 180 million individuals with obesity is projected to reach 450 million by 2025, making India the world’s most affected nation.^3,4 In 2019 obesity-related costs were estimated at US$ 28.95 billion (1% of India’s GDP). By 2060 these costs are expected to rise nearly 29-fold to US$ 838.6 billion (2.5% of GDP).⁵

Among India’s 250 million adolescents, 7.3 million boys and 5.2 million girls were obese in 2022- a dramatic increase from 0.2 million in 1990.^3,4 Indian children, like their peers worldwide, are now exposed to diets high in fat, sugar and salt; sedentary routines; extended screen time; and risky behaviours, including tobacco and alcohol use, substance abuse, unsafe sex, interpersonal violence and self-harm.^6,7 Addressing these risk factors early is critical to averting future NCDs.

Schools reach most school-age children and therefore offer a strategic platform for health promotion.⁸ Responding to this opportunity, the Government of India, under the larger Ayushman Bharat initiative, launched the School Health and Wellness Programme- a joint effort of the Ministries of Education and Health and Family Welfare.⁹ The programme provides health education and services while creating a supportive environment in which students learn from peers, teachers and other role-models.

Schools are targeted because healthy habits are easier to establish in childhood than to modify in adulthood. However. the programme also recognizes that students could serve as potential health advocates for behaviour change in their families and communities. Personal advocacy here denotes a student’s commitment to influence others to avoid harmful risk factors and adopt protective behaviours. Such student advocates could be especially valuable in contexts where public-health resources are limited.⁹

Consequently, the school health programme must achieve two goals: help students adopt healthy behaviours and empower them to advocate these behaviours to others. Key questions remain: Will teacher-led education alone suffice to produce student advocates? What type of school learning strategies most effectively nurture sustained advocacy? To explore this issue, we used tobacco prevention as a test-case, comparing two approaches for delivering anti-tobacco messages to pupils. Specifically, we asked which approach better promoted students’ consistent advocacy of tobacco prevention within their families and communities. This test-case could help inform strategies used by the government’s school health programme.

METHODS

Study setting and design

This study was conducted in four rural districts of Maharashtra, India’s second-most populous state, where 16.7% of agricultural land is devoted to tobacco cultivation. Adult tobacco-use in Maharashtra declined from 31.4% in 2009-2010 to 26.6% in 2016-2017, yet youth tobacco-use rose by 3% during the same period.¹⁰ Among Maharashtra’s 100,000 schools, roughly two-thirds are government-managed, enrolling 13 million students, mainly from lower-socio-economic, rural backgrounds. All government schools are required to comply with national tobacco-control legislation and tobacco-free school (TFS) guidelines.¹¹

We used a post-test-only quasi-experimental design to assess whether adding an external health-education facilitator to the usual TFS training of an assigned school teacher affected student advocacy for tobacco prevention in the family and community. Four districts were purposively selected: two were assigned to the intervention condition (teacher training + external facilitator) and two to the comparison condition (teacher training only). Districts for intervention were determined by state authorities. Data were collected once, after the intervention, from 1348 grade-8 students in randomly chosen government schools in these four districts. The post-intervention student survey was administered between April and May, 2023.

In order to be eligible for the post-only survey, students had to be grade 8 students enrolled in government-managed schools in the four districts, able to complete the Marathi questionnaire, present on the survey day, bring parental consent and provide student assent. Non-grade 8 students; students absent on the survey day; lacking parental consent or assent; or from schools outside the sampling frame were not eligible.

Intervention procedures

The department of education instructed principals in all four districts to nominate at least one non-tobacco-using teacher involved in health education. Nominated teachers were trained to implement tobacco-prevention activities in their schools.¹¹ They attended a one-day session covering tobacco harms, legal regulations, practical steps for enforcing TFS policies, how to conduct classroom lessons, awareness campaigns and village rallies with students.

In the two intervention districts, each school also received support from a paid facilitator recruited by an NGO. Facilitators- recent graduates with strong communication skills- completed a five-day course on health education, tobacco prevention and hygiene activities. These external facilitators visited the intervention schools to conduct additional classroom-based sessions for students on tobacco prevention, health and hygiene.

Random assignment of districts was not feasible, as the state administration selected the districts. Thus, all four districts received TFS training, but only the two intervention districts had the added resource of a trained external facilitator. Both interventions were completed in the academic year between September 2022 and March 2023.

Sampling and data collection

Lists of government schools were compiled for two blocks per district. Within each list, schools were selected by random-number draw until the target sample was reached: 596 students from 24 schools in the comparison districts and 752 students from 26 schools in the intervention districts. Two trained research facilitators administered a structured Marathi-language questionnaire during class time. Teachers were absent to ensure privacy and reduce any bias in responses by students. Facilitators read each question aloud while students marked paper questionnaires. Training of facilitators covered rapport-building, standardized delivery, confidentiality and accuracy. Approvals were taken from Salaam Mumbai Foundation’s internal committee, district education officers and school principals. Parents provided written consent and students assented.

Study instrument

The questionnaire captured age; gender; awareness of six ill-effects of tobacco (yes/no); knowledge of seven tobacco-related diseases (yes/no); awareness of the nine TFS criteria and of the 2003 Cigarettes and Other Tobacco Products Act (COTPA); perception of TFS implementation (nine yes/no items); participation in four school tobacco-prevention activities (yes/no); and four items scored as never (0)/sometimes (1)/always (2) assessed student’s ability to refuse tobacco offered by friends; ability to persuade a family member to stop using tobacco; active efforts to spread awareness of tobacco harms to family members; active efforts to spread awareness in locality/community (Table 1).

Data analysis

Data were entered in Microsoft Excel and analysed with SPSS v16.0. Descriptive analysis was generated for all variables. A dependent variable- commitment to personal advocacy- was created by summing two items: active efforts to raise awareness among family and active efforts to raise awareness in the community. Students scoring 4 (always + always) were classified as consistently committed; all others were categorized as inconsistently committed.

Chi-square tests examined associations between commitment to personal advocacy and dichotomous predictors. Independent-samples t-tests compared continuous predictors.

Four composite independent variables were constructed: 1) Ill-effects awareness score (0-6): sum of yes (1) and no (0) responses to 6 items on tobacco-related harms (e.g., bad breath, teeth and lip discoloration, tooth decay, risk of addiction, COVID-19 or respiratory infections, and hunger suppression). Scores ranged from 0 to 6. 2) Disease-knowledge score (0-7): sum of yes (1) and no (0) responses to 7 items on diseases linked to tobacco use (e.g., tuberculosis, obesity, cancers, sinusitis, diabetes, heart disease, asthma). 3) Perceived TFS-implementation score (0-9): sum of yes (1) and no (0) responses to 9 dichotomous items related to TFS criteria implementation in the school. 4) Participation score in tobacco-prevention activities (0-4): sum of yes (1) and no (0) responses to 4 items.

Predictors significant at p≤0.05 in bivariate tests were entered into a logistic-regression model with commitment as the outcome.

RESULTS

A total of 1348 students completed the survey, including 596 from comparison condition (schools that received the universal teacher training for TFS) and 752 from intervention condition (schools that received the teacher training for TFS and an additional external facilitator). Male and female proportions were roughly the same. The average age of participants was 14.4 years, with a median of 14 years. Over 80% of the participants knew that tobacco use caused cancers and understood the ill-effects of tobacco (e.g., bad breath, tooth decay, discoloration of teeth and lips, and risk of addiction). Nearly 49% (293) of 596 students who received TFS-only as compared to 40% (302) of 752 students who received teacher plus external facilitator reported consistent commitment to tobacco-prevention advocacy.

Table 1 compares consistently and inconsistently committed students. There was no age difference. Consistent advocates were more likely to be male (55%) and demonstrated higher scores for ill-effects awareness (mean 4.87/6) and disease knowledge (mean 4.75/7).

Two-thirds (67%) of consistent advocates knew of COTPA compared with 36 % of inconsistent advocates. Consistent advocates also perceived greater fulfilment of TFS criteria in their schools (mean 6.55/9) versus the inconsistent group (mean 5.03/9). The consistent group more frequently reported the presence of shops selling tobacco within 100 yards.

Participation in tobacco-prevention activities was higher among consistent advocates (mean 2.89/4) versus the inconsistent group (mean 2.61/4). The consistent advocates also scored higher on refusal self-efficacy (mean 1.71/2) versus the inconsistent group (1.31/2) and persuasion self-efficacy (mean 1.86/2) as compared to inconsistent (mean 1.24/2).

Table 2 presents the logistic-regression results. After adjustment, factors positively associated with consistent advocacy were: being in the teacher-only condition; awareness of COTPA; higher perceived fulfilment of TFS criteria; stronger refusal self-efficacy; and stronger persuasion self-efficacy.

DISCUSSION

This quasi-experimental post-test-only, study examined what type of school intervention for tobacco prevention had a greater effect on personal advocacy of tobacco-prevention or consistent commitment to spreading awareness among family and community members about tobacco prevention among students from government schools in four rural districts in the state of Maharashtra, India. Adolescents either belonged to schools in comparison districts where a universal tobacco-free school (TFS) training intervention was provided to teachers from government schools and the teachers conducted all activities or to schools in intervention districts where in addition to the TFS teacher-training, an external paid and trained facilitator was also deputed to conduct classroom sessions with students.

This post-test-only quasi-experimental study assessed which of two school delivery models better fostered adolescent advocacy for tobacco prevention. Students from teacher-only schools were more likely to be consistent advocates than those exposed to the additional external facilitator. One explanation is that students may respond more strongly to established authority figures within the school hierarchy than to facilitators who are temporary and outsiders- an effect noted in earlier school-based social-programme research.^12,13

It is also possible that students in teacher-only schools felt implicit pressure to report favourable advocacy behaviour, whereas external facilitators elicited more candid responses.

Prior research has also found that school-based social programs tend to be more effective when implemented by teachers rather than outside professionals, with the established teacher-student relationship playing a key role in fostering better student responsiveness to teacher-led interventions.^12,13

Further qualitative research is needed to probe the dynamics of whether a teacher-only intervention effectively cultivates consistently committed advocates, and to explore whether teacher-only models also reduce actual student tobacco use- a variable not captured here. Other studies have found that TFS-only intervention is linked with reduced tobacco use in students; however, those students whose family members used tobacco were less likely to give up tobacco.¹⁴ All this information could provide valuable evidence for large-scale government school-health program, including the government’s NCD-prevention initiative, that designates teachers as health ambassadors.⁹

Male students were more likely to be consistent advocates, reflecting broader gender norms in India that grant boys greater autonomy and public voice.^15,16 Consistent advocacy was also linked to knowledge (ill-effects, diseases, COTPA) and to self-efficacy in refusing offers and persuading others- findings aligned with previous research.¹⁷ Those who scored higher on ability to refuse when friends offered tobacco and on the ability to persuade family or friends to stop tobacco-use were significantly more likely to be ‘consistently committed’ to personal advocacy. These two variables most probably reflect greater self-efficacy in assertiveness skills. Studies have shown that youth empowerment programs that include assertiveness and advocacy training lead to increased self-efficacy and proactive engagement in tobacco control activities.¹⁸

Schools are ideal venues for integrating health and education goals.^9,19 Encouraging students to adopt healthy behaviors and advocate for them within their networks is an effective strategy, particularly in low and middle income countries (LMICs) like India. Advocacy fosters self-awareness, commitment, and motivation, as promoting a behavior often leads to its personal adoption. Publicly endorsing healthy behaviors creates accountability, while social pressure from peers reinforces adherence. Additionally, researching and learning about behaviors during the activity of advocacy can deepen understanding and facilitate personal change.⁹ This research highlights the potential of teachers as change agents in schools to influence student health behavior. The absence of baseline data limits causal inference. Exposure to other tobacco-control initiatives in comparison districts cannot be excluded. Self-reported behaviours may be biased by social desirability despite teacher absence during data collection. Finally, the sample- rural, Marathi-medium government schools- may not represent all Indian contexts.

CONCLUSION

Teacher-led implementation of the tobacco-free school programme produced more consistently committed adolescent advocates than a model supplemented by external facilitators. Further research should clarify causal mechanisms and understand why teacher-led interventions were more impactful. However, these findings reinforce the government’s strategy of using teachers as school ambassadors for scalable NCD prevention. Multi-component approaches combining school programmes, parental engagement, media and community partnerships remain essential for durable tobacco prevention and broader NCD risk reduction among youth.

ACKNOWLEDGEMENTS

Authors would like to acknowledge the students, teachers, principals, headmasters and staff of the participating schools, the district and block level officials, and the staff of Salaam Mumbai Foundation (SMF) who supported this project.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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