Abstract
Background: In India, 267 million adults use tobacco with prevalence of 35% in rural areas and 13% among those between 15 and 24 years. With 40% of India’s population below 19 years, tobacco-free schools (TFS) can be a critical strategy for preventing tobacco-use among youth. This study examined the extent of and factors associated with complete adherence to national TFS guidelines among rural schools in the state of Maharashtra. Methods: Trained observers visited 507 rural schools to check adherence to eleven TFS criteria and conducted a cross-sectional survey of school-level indicators. These data were coupled with school-based information from the District Information System for Education (DISE) to analyze factors associated with TFS-adherence. Results: Only 11% of schools adhered to all eleven TFS criteria. Majority (72%) prohibited sale of tobacco inside and within 100 yards of the school; 63% displayed no-smoking posters; and 59% banned tobacco use inside premises. However, only 18% consulted with state tobacco advisor and only 28% of schools had tobacco prevention messages on school stationery. Bivariate analysis revealed that complete TFS-adherence was associated with participation of school in sports (p<0.001) and extra-curricular competitions (p<0.001); internet connectivity (p<0.005) and e-learning facilities (p<0.05); and teachers’ attendance at capacity-building workshops (p<0.05). A logistic model identified competitive sports participation (OR=3.27, p<0.005) as a key predictor of adherence to the TFS policy. Conclusion: This is the first study in India that measures and examines compliance among rural schools with national TFS guidelines; thus filling an existing gap in the tobacco control literature. Schools that provide students and staff with opportunities for overall development seem more likely to implement tobacco-free guidelines. By understanding the hard-to-meet criteria, policy-makers and practitioners can support schools in becoming tobacco-free. Integrating tobacco control programs with overall development goals of the school is one way forward.