Predictors and prevalence of nicotine use in females: A village-based community study.

BACKGROUND: Nicotine use and abuse is gaining increasing attention due to its negative and serious medical consequences. Multiple morbidities occur due to the intake of nicotine in various forms. AIMS: To find the prevalence and type of nicotine use/abuse in females. SETTINGS AND
DESIGN: House to house survey in a village in Purvanchal, i.e. eastern part of Uttar Pradesh and bordering Bihar.
MATERIALS AND METHODS: Semi-structured performa was used to collect data; a house to house visit was made to collect data. STATISTICAL ANALYSIS: Simple percentages were calculated.
RESULTS: Tooth powder form of nicotine use is common and the need to address this problem is urgent.
CONCLUSIONS: Widespread dissemination of knowledge and legislative measures have to be undertaken to stop the problem.

Socioeconomic inequality is widely prevalent in India, especially so in urban areas.[12] Socioeconomic disadvantage is inextricably linked to several behaviors that influence health, tobacco being one of them.[3] The rate of smoking is expected to increase by 3% every year, leading to 1 million deaths annually by 2010.[45] After China, India is the second highest consumer of tobacco in the world.[67] Currently, about 230 million males and 11.9 million females consume tobacco in India.[8] Strategies designed to alleviate tobacco use in India are unfruitful because of its consumption in varied forms.[69] Owing to the variety of tobacco products consumed in India, varying health consequences are encountered, e.g. higher rate of oral cancer,[10] increased incidence of tuberculosis (TB), increased incidence of cervical cancer,[11] and complications of pregnancy.[12] Use of all forms of tobacco is associated with higher all-cause mortality in the Indian population.[13] The commonest form in which smokeless tobacco is used is “mishri” or “gul,” a black powder obtained by roasting and powdering tobacco, meant to be applied to the gums like a toothpaste.[9] Another common form is chewing of betel quid[13] which is a combination of betel leaf, areca nut, slaked lime, tobacco, and condiments. The smokeless forms of tobacco consumption in India include chewing of tobacco and inhalation of snuff.[1415] Chewing tobacco is consumed in the form of gutkha and zarda.[6] Gutkha, a sweetened mixture of tobacco, betel, and catechu, is sold in brightly colored packets; it is commonly used by children and women who chew it and then spit out the remaining portion.[1617] Zarda, a dried and colored residual tobacco, is obtained by boiling tobacco leaves with spices and lime.[17] In comparison to men, Indian women are much less likely to smoke tobacco (3.4 vs. 33.3%), chew tobacco (13 vs. 29%), and use tobacco in smoke and smokeless forms (15.5 vs. 50.2%).[1618]

Among the tobacco users, bidi smokers constitute 40%, cigarette smokers 20% and those using smokeless forms 40%.[9] The prevalence of tobacco use in 1993–1994 was 23.2% in males (any age) and 4% in females (any age) in urban areas, and 33.6% in males and 8.8% in females in rural areas.[13] The National Family Health Survey[5] had revealed that individuals with no education were 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. This study had also shown that households belonging to the lowest fifth of a standard living index were 2.54 times more likely to consume tobacco than those in the highest fifths.[19] Thus, illiteracy and poverty were associated with tobacco consumption in India.[13]

Although smoking by women is a taboo in the Indian society,[2021] consumption of smokeless tobacco is well accepted and use of mishri (tobacco containing teeth cleaning powder) or “gul” is very common.[2223] Various studies have estimated the prevalence of the use to be from 17 to 45%.[23] In the state of Uttar Pradesh, the prevalence of tobacco use in females is 9.1%,correction is ok) out of which 7.6% females use the smokeless variety.[9] Females form a vulnerable group due to various factors like illiteracy, poverty, malnutrition, child bearing, multiple pregnancies and social inequality.[24] Awareness regarding the ill effects of tobacco and its exposure to the unborn child is minimal. Most of the females are not aware of the tobacco content of the toothpaste variety, as adequate legislative measures are lacking.[1825] The above-mentioned factors increase the magnitude of the problem. There is a paucity of data related to tobacco intake in females from the eastern Uttar Pradesh region. Hence, the present study was undertaken to address this gap in information.

Aim of the study

The study was undertaken with an aim to find the prevalence of nicotine use in the female population of a rural community, the pattern of nicotine use, and the level of awareness regarding nicotine use, and to try and explore the predictors of use of different forms of tobacco in this population. In the present article, the terms tobacco and nicotine will be used interchangeably.

MATERIALS AND METHODS

The present study was conducted in Tikari village which is located 10 km away from the university and is a part of the community outreach of Community Medicine Department. All females above 10 years of age were examined on semi-structured Performa which included data about the general socio-demographic features and type, quantity, duration of tobacco use, awareness about the content of the product and its medical complications, and presence of any physical complications in the subject. At the end of the study, all the participants were given active education in group setting, and if needed, individual reference was done to the hospital tobacco cessation and control center (TCC). Participants having other complications were referred to the specified departments of the hospital and were actively monitored on a longitudinal basis regarding their well-being. Before examining the subjects, a written informed consent was taken; in the case of an illiterate participant, consent was taken by informing the individual and taking the thumb impression. The study was approved by the institute ethical committee.

RESULTS

Table 1 shows the salient statistical features of Tikari village. The education level of the village is better than the national average;[5] this is mainly due to its close proximity with the town and as a result of the active outreach services. The number of females above 10 years was 3847 (47.3%), and the number using tobacco in any form was 352.23 (9.4%). The use of smokeless form was much higher (80% vs. 20%) [Figure 1 and Table 2].

Table 1

Socio-demographic features of Tikari village

Figure 1

Form of nicotine use

Table 2

Type of tobacco use

Predominantly tobacco was used in the form of pan (betel leaf with lime catechu and tobacco), khaini (chewable tobacco mixed with lime) and gul (toothpaste form of tobacco) [Figure 2 and Table 3]. Commonly, multiple forms of tobacco consumption were prevalent in the subjects (60 vs. 40%) [Figure 2 and Table 4]. About 77% females were unaware of the nature and nicotine content of the product being consumed, this aspect was more apparent in toothpaste and lip balm variety of tobacco use [Figure 3]. The consumption of tobacco showed two peaks between 30–40 years and after 50 years [Figure 4 and Table 5].

Figure 2

Types of nicotine use

Table 3

Pattern of use

Table 4

Overlap in nicotine use

Figure 3

Awareness about nicotine use

Figure 4

Age-related type of consumption of nicotine

Table 5

Age-wise use of nicotine

DISCUSSION

Our study area was a comparatively literate and financially well-to-do village in contrast to the national data.[5] The percentage of females in the village is in keeping with the national average.[5] Our study found about 9% females to be using tobacco; this is same as that reported in other surveys and studies.[2627] Most common form of use in females was smokeless variety, out of which the toothpaste form was more popular; this finding was also reported by other studies.[25] The toothpaste form is more dangerous as it is used in an unsuspecting form and commonly by the reproductive age group, thus leading to the likelihood of in utero complications.[24] The easy availability and lack of awareness regarding the product lead to its increased consumption.[28] Most of the knowledge dispersed focuses on the popular forms like gutka, zarda, khaini,[16] and smoked varieties like bidi and cigarette.[29] Predictably, the smoked form was used by fewer females (20%); various other surveys give a similar picture.[1630] Our finding assumes importance since the study site was a village which is monitored by the hospital and has a primary health center and a primary school, is connected by a motorable road, has access to government welfare schemes, and is nearer to town. The high use of tobacco by females in this scenario highlights the “unknown” nature of use.[31] Our study found that there are certain predictors of tobacco use in females, e.g. gul, i.e. toothpaste variety, is used by females in the age group of 25–45 years, those belonging to middle- and upper-income group, and those likely to be economically independent; as the usual employment for females is vegetable selling, most often these females suffer from toothache and headache. Use of gul for toothache is a common practice in the villages, leading to the subject becoming an unsuspecting addict who is compelled to take it in order to stop the withdrawal symptoms.[29] In contrast, surti, khaini form of nicotine is used by females of age 40–60 years, belonging to lower-income group, having one male member who is a regular user or a friend who is a nicotine user. These findings are interesting as they have not been reported in any study so far and also because these have a direct implication on the health givers and policy framers.[3233] In case of toothpaste variety, emphasis should be on the reproductive health,[25] and the middle-aged women should be examined to rule out any precancerous lesions.[24] To conclude, our findings emphasize the need for a stringent law which is applicable to all forms of nicotine containing products.[34] Unsupervised selling at open shops should be curbed by appropriate measures; statutory warning like the one that cigarette packs carry should be made compulsory on all tobacco containing products.[35] Routine medical examinations should also include a nicotine screening test.[36] The limitation of our study is that we did not try to rate the severity of nicotine dependence, or the medical or mental co-morbidities, as has been seen in other studies.[3337] We did not examine the subjects regarding the presence of nicotine-related complications; however, we did active referrals in those subjects where it was indicated.[16] To be helpful in the formulation of a strategy, our study needs to have a larger sample; alternatively, a study of nicotine intake needs to be carried out on the medically and psychiatrically ill females and an attempt to correlate the complications of nicotine intake with the type and amount of nicotine consumption should be attempted.