Introduction

Smokeless tobacco (SLT) is any kind of tobacco that is consumed through mouth or nose without any burning which includes Khaini/Surti, Gutkha, Zarda, snuff, and as an ingredient of Paan masala [1, 2]. There are approximately 16000 unique flavors available in some markets, many of them appealing to children [3]. Tobacco is one of the biggest epidemic public health threats and kills half of the users who don’t quit in their lifetime [4]. It contributes to poverty by diverting spending on basic needs such as food and shelter to tobacco [5].

Tobacco is one of the world’s leading causes of preventable death. It is responsible for killing nearly 8 million persons every year [5]. The use of smokeless tobacco is highly addictive and damaging to health, containing many cancer-causing toxins. Its use increases the risk of cancers of the head, neck, throat, oesophagus, and oral cavity (including cancer of the mouth, tongue, lip and gums) as well as various dental diseases [6]. An estimated 1.3 billion people use tobacco products globally, among them 80% of users live in low-and middle-income countries (LMICs) [5]. In 2020, 22.3% of the world’s population used tobacco: 36.7% of men and 7.8% of women [5].

Almost 81% of the world’s smokeless tobacco users live in the South-East Asian Region (SEAR) [5]. The proportion of adolescent students who had ever used smokeless tobacco accounted for 11.2% in Egypt, 9% in Kenya, 12.5% in India, 16.2% in Nepal, and 11.9% in Norway [7]. In response to control the tobacco epidemic, all the World Health Organization (WHO) member states adopted the WHO Framework Convention on Tobacco Control (WHO FCTC) in 2003 and currently 182 countries are parties to this convention. Furthermore, the WHO introduced the MPOWER strategy in 2007 which is a practical, and cost-effective initiative to scale up the implementation of the demand reduction provisions of the WHO FCTC [8].

The step-wise approach to non-communicable disease risk factor surveillance (STEPS) survey of 2019 Nepal, reported that 18.3% and 15.3% of the population aged between 15–69 years were current and daily smokeless tobacco users in Nepal respectively [9]. Most current smokeless tobacco users were males (33.3%) compared to females (4.9%) [9]. A national adolescent survey i.e., Global Youth Tobacco Survey 2011 (GYTS) revealed that 16.2% of the individuals aged between 13–15 years were current smokeless tobacco users, among them, boys (19.7%) and girls (12.9%) [10]. These findings highlight a tremendous increase in tobacco users from 7.2% in 2001 to 8% in 2007 to 19.1% in 2011 [10]. In response to control the tobacco epidemic in Nepal, the government of Nepal (GoN) introduced the Tobacco Product Control Act in 2011 ensuring legal provisions to reduce, control, and regulate the import, production, sale, distribution, and consumption of tobacco products [11].

The most prevalent tobacco-related causes of death are cardiovascular disease (53%), chronic respiratory disease (21%), and cancer (8%) [12]. According to the Census 2021 of Nepal, around 20% of the total population was contributed by the young population aged 10–19 years [13]. Adolescents are the most vulnerable age group to any tobacco use and addiction to nicotine. Smoking at a young age increases the risk of various non-communicable diseases such as respiratory illness, asthma, chronic obstructive respiratory disease (COPD), reduced pulmonary function, and cancers [14].

The use of smokeless tobacco is also common, particularly in the Terai belt of Nepal, and is gradually spreading to other parts of Nepal. Previous studies show that tobacco use in Nepal is more common among those with lower education, poor economic status, and adolescents [15]. However, there is limited data on the prevalence, distribution, and trends of tobacco use nationally. Updated information on current usage patterns would aid policymakers in addressing the tobacco epidemic. The prevention of tobacco use among adolescents is the greatest opportunity for preventing non-communicable diseases in Nepal. Hence, this study aimed to determine the prevalence of smokeless tobacco and its associated factors among secondary school students of grades 11 and 12 in Rangeli Municipality, Nepal.

Methodology

Results

Characteristics of the participants

A total of 355 students participated in this study. The mean (±SD) age of the participants was 18.0±1.3 years. The majority of them were female (61.1%), from grade 11 (58.3%), and government school (60%). Most of them belonged to the nuclear family (64.8), Madhesi ethnicity (61.6%), and Hindu religion (95.2%). The majority of the participant’s fathers had completed secondary education (40.3%) while the majority of their mothers did not have any formal education (40.8%) (Table 1).

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Table 1. Individual characteristics of the study participants.

https://doi.org/10.1371/journal.pone.0313288.t001

Smokeless tobacco use

Table 2 shows that 38.4% and 61.6% of the participants were SLT ever users and never users, respectively. Among ever user of SLT, 29.5% were current users. Most participants who tried SLT for the first time were at the age of 10 to 14 years (47.7%).

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Table 2. Prevalence of smokeless tobacco use among the study participants.

https://doi.org/10.1371/journal.pone.0313288.t002

Smokeless tobacco cessation

Table 3 shows that only 19.4% wanted to stop using SLT whereas 24.5% of them tried to stop using it during the past 12 months. Most of the participants (21.4%) didn’t receive help or advice from anyone to stop using SLT.

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Table 3. Smokeless tobacco cessation among the study participants.

https://doi.org/10.1371/journal.pone.0313288.t003

Preferred SLT among ever-users tobacco users (n = 136)

Fig 1 shows that gutka (40.16%) and paan masala (45.08%) were the most preferred SLT among the participants.

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Fig 1. Preferred SLT among ever-used tobacco users.

https://doi.org/10.1371/journal.pone.0313288.g001

Opinions on smokeless tobacco use

The majority of participants (63.1%) think that there is no difference in using SLT at celebrations, parties, or other social gatherings. Nearly half of the participants disagreed that people might enjoy using SLT. Home and public places were the most common sites for smoking. Only 42% had heard about the Tobacco Control Law in Nepal (Table 4).

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Table 4. Opinion on smokeless tobacco use among the study participants.

https://doi.org/10.1371/journal.pone.0313288.t004

The reasons for smoking or chewing tobacco (Multiple response question)

Fig 2 shows that participants revealed that the most common reasons for chewing or smoking were to have fun (50.1%) and peer pressure (26.0%).

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Fig 2. Reasons for smoking and chewing tobacco.

https://doi.org/10.1371/journal.pone.0313288.g002

Media anti-tobacco

Most of the participants (85.1%) didn’t ever see any signs stating that adolescents are not allowed to buy tobacco products. The majority of them had seen anti-smoking media messages on television i.e., only a few times (37.5%). While most of the participants were unaware of the anti-tobacco messages in newspapers/magazines (71.3%) and at the point of sale (80.8%) (Table 5).

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Table 5. Media anti-tobacco among the study participants.

https://doi.org/10.1371/journal.pone.0313288.t005

Factors association with the prevalence of smokeless tobacco

Table 6 shows that age (AOR = 1.5, CI: 1.2–2.2), sex (AOR = 2.6, CI:1.6–4.4), and school type (AOR = 1.8, CI:1.1–3.0) and ever seen anti-tobacco messages in newspapers/magazines (AOR = 0.5, CI: 0.5–0.8) were significantly associated with the prevalence of SLT.

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Table 6. Factors associated with smokeless tobacco use.

https://doi.org/10.1371/journal.pone.0313288.t006

Discussion

The tobacco epidemic is one of the biggest public health threats and the world’s leading cause of preventable death which is responsible for killing 8 million people every year. The use of smokeless tobacco is common, particularly in the Terai belt of Nepal, and is gradually spreading to other parts of Nepal. This study aimed to determine the prevalence of smokeless tobacco and its associated factors among secondary school students of grades 11 and 12 in Rangeli Municipality, Nepal.

This study found that the prevalence of the current smokeless tobacco users was 29.5% among the students. A similar finding was observed in a study conducted in India (24%) [19], the United States (23%) [20] and Nepal (20.1%) [21]. However, our finding is higher than that of the Nepal STEPS Survey 2019 [22]. This study showed that more than one-third tried smokeless tobacco throughout their lifetime which is consistent with a similar study conducted in Kathmandu, Nepal [21]. The noticeable prevalence of SLT is due to low taxation on SLT products [23]. Another obvious reason is that being closer to the Indian border, many imports and illegal production of SLT are growing within the country, making it easily accessible [23].

This study reported that nearly half of the students started using SLT between the ages of 10 to 14 years. This finding is supported by a study done in Bangladesh [24]. Similarly, a study conducted in Kathmandu Valley, Nepal showed that students aged 11 to 19 years started using SLT (62.2%) [25]. In contrast to our study, a previously conducted study in western Nepal revealed that students aged 15 years and above started using SLT [26]. Younger adolescents are more susceptible to tobacco use and smoking due to factors like curiosity, relieving tension, peer pressure, and the influence of media which can lead to starting tobacco use at a younger age [25, 26].

A maximum proportion of secondary school students used tobacco or smoked at most 5 times per day (89.5%) which is higher than the annual survey conducted by the Department of Health Services, Nepal in 2023/24 [27].

In this study, one in five current SLT users want to stop using tobacco which is similar to a study conducted among adolescents in Bangladesh [24]. Furthermore, one in four (24.5%) current SLT users ever tried to stop using SLT which is higher than that of the Nepal STEP Survey 2019 among adults (17.9%) [22]. The school students might have seen or heard about the burden of tobacco leading to various diseases like cardiovascular diseases, diabetes and kidney diseases, neoplasms, and non-communicable diseases like tuberculosis, and cancer [28]. However, this finding is lower than the students who tried to quit the habit of using tobacco in western Nepal [26] and the study conducted on public health undergraduates in Nepal [25].

Of those participants who received help or advice to stop using SLT, 16.1% sought it from family members whereas the Nepal STEPS Survey 2019 reported that 21% of SLT users sought help from healthcare providers [22]. Contradictory, this finding is lower than a similar study done in Kathmandu Valley, Nepal which showed that 73.8% ever users received help or advice to stop using tobacco and cigarettes [25]. However, 21.4% of the ever SLT users did not seek help from anyone in this study. It might be because adolescents often believe smokeless tobacco is a safer alternative to smoking, making them less likely to seek help for quitting tobacco use [29].

Unfortunately, nearly one-third of the participants had not seen health warnings on SLT packages, which is consistent with a study conducted in India (27%) [30]. The trend in the decrease in noticing the health warning labels among SLT quitters could be explained by the fact that they were no longer regularly exposed to SLT packaging [30]. Another reason is, a substantial minority were not even aware that there were health warning labels on SLT products [30]. Most SLT users have seen the warning signs on tobacco packages, but those users who cannot read, have not seen the warning messages on tobacco packages [31].

Most of the students preferred Paan masala (45.08%) and Gutkha (40.16%) which is slightly comparable with the study conducted in western Nepal i.e., Paan masala (42.9%) and Gutkha (20.7%) [26] and another study conducted on Nepalese students [32]. However, Zarda was preferred the most in Bangladesh [24].

According to our study, most students revealed that home and public places were the most preferable sites for tobacco use [31]. This finding is supported by a previously conducted study in Nepal among Nepalese students [32] and Sri Lanka among males [31]. It is due to tobacco users feel safe at home as they might have more freedom [31, 32]. This demonstrates that they are somewhat in control of their smoking habits and public place behaviors [26, 31, 32].

To have fun, peer pressure, to relieve pain and the influence of family members/movie actors were the influencing factors for tobacco consumption. It is comparable to a study conducted in Nepal [26, 32] and systematic review done to investigate the reasons for using smokeless tobacco [33]. It is due to SLT products are mostly imported from India and are easily accessible to the public [33]. Another reason is, that the general public is often unaware of the health risks linked to smokeless tobacco use [32], misconceptions about the health benefits of these products, perpetuated by traditional health messages and long-held beliefs, may encourage their consumption [30, 32, 33]. The primary factor for initiation was the influence of family members. SLT users also believed that it protected them from evil spirits and dangerous reptiles [33]. Also, a significant proportion of younger adolescents are still unaware of the Tobacco Control Law within the country of Nepal [25].

Only a minority of the participants had seen anti-smoking media messages quite a lot on television, and even fewer in cinema halls. On the contrary, this finding is lower compared to the Nepal STEPS Survey 2019 among adults [22]. This finding suggested that anti-tobacco media messages should be promoted and expanded to the community level, workplaces, and educational institutions to aware of the harmful use of tobacco and to control tobacco consumption [31, 34].

The higher age group was 1.5 times more likely to use SLT than the lower age group in this study. A similar pattern was observed in a study conducted by Pérez et al., 2022 [35], in Kathmandu, Nepal [21] and among public health undergraduates in Nepal [25]. These are emerging adults who have moved away from their families for the first time and are faced with unprecedented freedom and might have received higher pocket money [35]. These factors could have made tobacco products more accessible to them. Young adults may be more likely to be around others who use tobacco, like friends or family members [25, 33]. This social influence can make them more likely to experiment and increase their impulse, making them more susceptible to peer pressure.

Male students had 2.6 times more odds of using smokeless tobacco than females. It is supported by several studies done in Sudan [7], India [19], Bangladesh [24], South-East Asia [36] and Nepal [23]. In the Nepalese context, smoking and other forms of tobacco are considered as acceptable behavior for men but not for women [23]. Male students are easily influenced by peer pressure for the initiation of tobacco use [35, 37]. Peer influence, rebelliousness, and thrill-seeking appear to predict smokeless tobacco initiation strongly among male youth [33]. Additionally, social norms and the prohibition of tobacco use can be one of the factors responsible for the lower prevalence of tobacco use in the female population in Southeast Asian countries [28].

Tobacco consumption was higher among private school students (24.5%) than government school students (19.6%). This finding is coherent with the study conducted among Nepalese students [32] and a similar study done in Cameroon [38]. This study demonstrated that private school students had 1.8 times higher odds of using SLT than government school students. In contrast, a study conducted in India revealed no difference in SLT consumption between private and government colleges [37]. This might be because private schools might receive more media attention regarding student behavior, making any isolated incident of tobacco use seem more prevalent.

This study depicted that family type was not associated with the prevalence of SLT which is in disagreement with the study conducted among Nepalese students [32] and Sudanese adolescents [7]. Similarly, the education of parents and their occupations were not associated with SLT consumption among the students [19, 39, 40]. However, several studies reported that family history of using tobacco/smoking, family’s monthly income, pocket money, and tobacco control policies are the determinants of tobacco consumption among school students.

Conclusion

This study demonstrated that young students, males, and students from private schools are at a greater risk of SLT use. Meanwhile, most students believed that the reasons for SLT use are to have fun, due to peer pressure, and to relieve pain without knowing the consequences on their health. Still a notable number of students are unaware of anti-tobacco messages on tobacco products, cinema halls, and at the point of sale.

Hence, concerned stakeholders must expand awareness and promote educational programs on the harmful use of tobacco targeting school students. All level governments, educational institutions, and private organizations should jointly work to strengthen the implementation of tobacco cessation programs and tobacco control strategies. Additionally, school-based interventions and programs should be carried out to control and prevent all kinds of tobacco use especially targeting school-going adolescents, males, and private schools.

Supporting information

Acknowledgments

We would like to thank the Central Department of Public Health, Institute of Medicine, Tribhuvan University, Nepal for their guidance. We would like to acknowledge Rangeli Municipality, Nepal for providing support to conduct the study. Also, we would like to thank all the participants who contributed their valuable time and efforts.