Effectiveness of a School Based Smokeless Tobacco Intervention: A Cluster Randomized Trial


To assess the effectiveness of intervention in improving knowledge, attitude and perception regarding smokeless tobacco (SLT) use and its harmful effects and intention to quit SLT among school going adolescents. A school-based cluster randomized control trial was carried out in 18 secondary schools targeting male and female students from grades 6 to 10 in Karachi. Primary outcome was knowledge about hazards of smokeless tobacco (SLT) and secondary outcomes were attitude and Perception about hazards of SLT, and intention to quit SLT. We enrolled 738 participants in intervention group and 589 in the control group. Mean score of knowledge significantly improved in intervention as compared to control group (P value < 0.01). Intention to quit was found to be proportionately higher (33%) in the intervention group as compared to control group. Generalized estimating equations were used to assess the association of factors with knowledge regarding harmful effects of SLT use. Significant predictors of increase in knowledge score were found in children: who had seen any anti SLT messages on social media in the past 30 days, who were getting information regarding harmful effects of SLT use in school or textbooks and who had friends using SLT. A school-based intervention was effective in increasing knowledge regarding the harmful effects of SLT use and intention to quit SLT use among school adolescents. Introduction of such educational programmes on a regular basis in schools or as part of school curriculum can have an impact on reducing prevalence of SLT use.

Trial Registration NCT03418506. https://register.clinicaltrials.gov/NCT03418506.

This is a preview of subscription content, log in to check access.

Fig. 1


  1. 1.

    Ahluwalia, K. P. (2005). Assessing the oral cancer risk of South-Asian immigrants in New York City. Cancer, 104(S12), 2959–2961.

    Article  Google Scholar 

  2. 2.

    Ahmad, K., Jafary, F., Jehan, I., Hatcher, J., Khan, A. Q., Chaturvedi, N., et al. (2005). Prevalence and predictors of smoking in Pakistan: Results of the National Health Survey of Pakistan. European Journal of Cardiovascular Prevention & Rehabilitation, 12(3), 203–208.

    Article  Google Scholar 

  3. 3.

    American Lung Association. Fact Sheet Teenage Tobacco use. Retrieved June 21, 2018, from http://www.lungusa.org/tobacco/teenager_factsheet99.html

  4. 4.

    Bhurgri, Y. (2005). Cancer of the oral cavity-trends in Karachi South (1995–2002). Asian Pacific Journal of Cancer Prevention, 6(1), 22–26.

    PubMed  Google Scholar 

  5. 5.

    Bhurgri, Y., Bhurgri, A., Hassan, S. H., Zaidi, S., Rahim, A., Sankaranarayanan, R., et al. (2000). Cancer incidence in Karachi, Pakistan: first results from Karachi Cancer Registry. International Journal of Cancer, 85(3), 325–329.

    CAS  Article  Google Scholar 

  6. 6.

    Bruvold, W. H. (1993). A meta-analysis of adolescent smoking prevention programs. American Journal of Public Health, 83(6), 872–880.

    CAS  Article  Google Scholar 

  7. 7.

    Center for Behavioral Epidemiology and Community Health. (1989). Prevention of tobacco use among adolescents in public schools in San Diego County, USA. Retrieved June 21, 2018, from http://www.sci.sdsu.edu/c_beach/abstract/tobacco3.html

  8. 8.

    Chen, G., Hsieh, M. Y., Chen, A. W., Kao, N. H., & Chen, M. K. (2017). The effectiveness of school educating program for betel quid chewing: A pilot study in Papua New Guinea. Journal of the Chinese Medical Association. https://doi.org/10.1016/j.jcma.2017.10.001.

    Article  PubMed  Google Scholar 

  9. 9.

    Chen, L., Chen, Y., Hao, Y., Gu, J., Guo, Y., & Ling, W. (2014). Effectiveness of school-based smoking intervention in middle school students of Linzhi Tibetan and Guangzhou Han ethnicity in China. Addictive Behaviors, 39(1), 189–195. https://doi.org/10.1016/j.addbeh.2013.09.026.

    Article  PubMed  Google Scholar 

  10. 10.

    Chen, X., Fang, X., Li, X., Stanton, B., & Lin, D. (2006). Stay away from tobacco: A pilot trial of a school-based adolescent smoking prevention program in Beijing, China. Nicotine & Tobacco Research, 8(2), 227–237. https://doi.org/10.1080/14622200600576479.

    Article  Google Scholar 

  11. 11.

    Ferlay, J., & International Agency for Research on Cancer. (2004). GLOBOCAN 2002: Cancer incidence, mortality and prevalence worldwide. Lyon: IARC Press.

    Google Scholar 

  12. 12.

    Guha, N., Warnakulasuriya, S., Vlaanderen, J., & Straif, K. (2014). Betel quid chewing and the risk of oral and oropharyngeal cancers: A meta-analysis with implications for cancer control. International Journal of Cancer, 135(6), 1433–1443.

    CAS  Article  Google Scholar 

  13. 13.

    Gupta, B., & Johnson, N. W. (2014). Systematic review and meta-analysis of association of smokeless tobacco and of betel quid without tobacco with incidence of oral cancer in South Asia and the Pacific. PLoS ONE, 9(11), e113385.

    Article  Google Scholar 

  14. 14.

    Gupta, P. C., Pednekar, M. S., Parkin, D. M., & Sankaranarayanan, R. (2005). Tobacco associated mortality in Mumbai (Bombay) India. Results of the Bombay cohort study. International Journal of Epidemiology, 34(6), 1395–1402.

    Article  Google Scholar 

  15. 15.

    Gupta, P. C., & Ray, C. S. (2003). Smokeless tobacco and health in India and South Asia. Respirology, 8(4), 419–431.

    Article  Google Scholar 

  16. 16.

    Jayakrishnan, R., Geetha, S., Mohanan Nair, J. K., Thomas, G., & Sebastian, P. (2016). Tobacco and alcohol use and the impact of school based antitobacco education for knowledge enhancement among adolescent students of rural Kerala, India. Journal of Addiction, 2016, 9570517. https://doi.org/10.1155/2016/9570517.

    Article  PubMed  PubMed Central  Google Scholar 

  17. 17.

    Johnson, C. A., Unger, J. B., Ritt-Olson, A., Palmer, P. H., Cen, S. Y., Gallaher, P., et al. (2005). Smoking prevention for ethnically diverse adolescents: 2-Year outcomes of a multicultural, school-based smoking prevention curriculum in Southern California. Preventive Medicine, 40(6), 842–852. https://doi.org/10.1016/j.ypmed.2004.09.032.

    Article  PubMed  Google Scholar 

  18. 18.

    Johnson, N. W., Warnakulasuriya, S., Gupta, P. C., Dimba, E., Chindia, M., Otoh, E. C., et al. (2011). Global oral health inequalities in incidence and outcomes for oral cancer causes and solutions. Advances in Dental Research, 23(2), 237–246.

    CAS  Article  Google Scholar 

  19. 19.

    Khawaja, M. R., Mazahir, S., Majeed, A., Malik, F., Merchant, K. A., Maqsood, M., et al. (2006). Chewing of betel, areca and tobacco: Perceptions and knowledge regarding their role in head and neck cancers in an urban squatter settlement in Pakistan. Asian Pacific Journal of Cancer Prevention, 7(1), 95.

    PubMed  Google Scholar 

  20. 20.

    Lee, P. H., Wu, D. M., Lai, H. R., & Chu, N. F. (2007). The impacts of a school-wide no smoking strategy and classroom-based smoking prevention curriculum on the smoking behavior of junior high school students. Addictive Behaviors, 32(10), 2099–2107. https://doi.org/10.1016/j.addbeh.2007.01.018.

    Article  PubMed  Google Scholar 

  21. 21.

    Loyha, K., Vatanasapt, P., Promthet, S., & Parkin, D. M. (2012). Risk factors for oral cancer in northeast Thailand. Asian Pacific Journal of Cancer Prevention, 13(10), 5087–5090.

    Article  Google Scholar 

  22. 22.

    Mazahir, S., Malik, R., Maqsood, M., Merchant, K. A. R., Malik, F., Majeed, A., et al. (2006). Socio-demographic correlates of betel, areca and smokeless tobacco use as a high risk behavior for head and neck cancers in a squatter settlement of Karachi, Pakistan. Substance Abuse Treatment, Prevention, and Policy, 1(1), 10.

    Article  Google Scholar 

  23. 23.

    Meier, E., Lechner, W. V., Miller, M. B., & Wiener, J. L. (2013). Changes in smokeless tobacco use over four years following a campus-wide anti-tobacco intervention. Nicotine & Tobacco Research, 15(8), 1382–1387.

    Article  Google Scholar 

  24. 24.

    Merchant, A., Husain, S. S., Hosain, M., Fikree, F. F., Pitiphat, W., Siddiqui, A. R., et al. (2000). Paan without tobacco: An independent risk factor for oral cancer. International Journal of Cancer, 86(1), 128–131.

    CAS  Article  Google Scholar 

  25. 25.

    Millstein, S. G., Irwin, C. E., Jr., Adler, N. E., Cohn, L. D., Kegeles, S. M., & Dolcini, M. M. (1992). Health-risk behaviors and health concerns among young adolescents. Pediatrics, 89(3), 422–428.

    CAS  PubMed  Google Scholar 

  26. 26.

    Murukutla, N., Turk, T., Prasad, C., Saradhi, R., Kaur, J., Gupta, S., et al. (2011). Results of a national mass media campaign in India to warn against the dangers of smokeless tobacco consumption. Tobacco Control, 21, 12–17.

    Article  Google Scholar 

  27. 27.

    Obaid, H. A., Hassan, M. A., Mahdy, N. H., ElDisouky, M. I., Alzarba, F. E., Alnayeemi, S. R., et al. (2015). Tobacco use and associated factors among school students in Dubai, 2010: Intervention study. Eastern Mediterranean Health Journal, 20(12), 765–773.

    CAS  Article  Google Scholar 

  28. 28.

    Orr, I. (1933). Oral cancer in betel nut chewers in Travancore: Its aetiology, pathology, and treatment. The Lancet, 222(5741), 575–580.

    Article  Google Scholar 

  29. 29.

    Park, E. (2006). School-based smoking prevention programs for adolescents in South Korea: A systematic review. Health Education Research, 21(3), 407–415. https://doi.org/10.1093/her/cyl038.

    Article  PubMed  Google Scholar 

  30. 30.

    Rozi, S., & Akhtar, S. (2007). Prevalence and predictors of smokeless tobacco use among high-school males in Karachi, Pakistan. Eastern Mediterranean Health Journal, 13(4), 916–924.

    CAS  PubMed  Google Scholar 

  31. 31.

    Rozi, S., Akhtar, S., Ali, S., & Khan, J. (2005). Prevalence and factors associated with current smoking among high school adolescents in Karachi, Pakistan. Southeast Asian Journal of Tropical Medicine and Public Health, 36(2), 498–504.

    PubMed  Google Scholar 

  32. 32.

    Sinha, D., Gupta, P., Pednekar, M., Jones, J., & Warren, C. (2002). Tobacco use among school personnel in Bihar, India. Tobacco Control, 11(1), 82–83.

    CAS  Article  Google Scholar 

  33. 33.

    Sun, P., Miyano, J., Rohrbach, L. A., Dent, C. W., & Sussman, S. (2007). Short-term effects of Project EX-4: A classroom-based smoking prevention and cessation intervention program. Addictive Behaviors, 32(2), 342–350. https://doi.org/10.1016/j.addbeh.2006.05.005.

    Article  PubMed  Google Scholar 

  34. 34.

    Tahlil, T., Woodman, R. J., Coveney, J., & Ward, P. R. (2013). The impact of education programs on smoking prevention: A randomized controlled trial among 11 to 14 year olds in Aceh, Indonesia. BMC Public Health, 13(1), 367. https://doi.org/10.1186/1471-2458-13-367.

    Article  PubMed  PubMed Central  Google Scholar 

  35. 35.

    Warnakulasuriya, S. (2009). Global epidemiology of oral and oropharyngeal cancer. Oral Oncology, 45(4), 309–316.

    Article  Google Scholar 

  36. 36.

    Warren, C. W., Riley, L., Asma, S., Eriksen, M. P., Green, L., Blanton, C., et al. (2000). Tobacco use by youth: A surveillance report from the Global Youth Tobacco Survey project. Bulletin of the World Health Organization, 78, 868–876.

    CAS  PubMed  PubMed Central  Google Scholar 

Download references


We are indebted to the District Officer of Education, City District Govt. Karachi and Town Administration Malir, Bin-Qasim and Gadap Towns for their support in conducting study. We acknowledge all the selected govt. and private schools for their participation. We would like to thank the study field team, especially MS Farida Baig, Ms Barkha Raj, Ms Yasmeen Mirzaman for their assistance as programme providers. We are greatly indebted to MS Naureen Akbar Ali for providing valuable support.

Author information




SR: conceived and designed the study, education material, data analysis, manuscript drafting and finalized. NZ: responsible for manuscript writing, and reviewing the paper and educational material. ML: assisted in data analysis, preparing educational material and supervised field activities. SS: data management and basic descriptive analysis. TR: contributed to manuscript drafting. AR: coordinated budget and logistics of the study. ZB: reviewed the final manuscript. All authors saw and approved the final version of manuscript.

Corresponding author

Correspondence to Shafquat Rozi.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

Ethical approval for the study was obtained for the institutional review board at Dow University of Health Sciences.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Rozi, S., Zahid, N., Roome, T. et al. Effectiveness of a School Based Smokeless Tobacco Intervention: A Cluster Randomized Trial. J Community Health 44, 1098–1110 (2019). https://doi.org/10.1007/s10900-019-00689-8

Download citation


  • Smokeless tobacco
  • Cluster randomized trial
  • Adolescents
  • School based intervention