A study on the prevalence and correlates of nicotine dependence among adolescents of Burdwan Town, West Bengal.

CONTEXT: Tobacco will cause one billion deaths in the 21st century. The use of tobacco causes dependence both psychological and physical. AIMS: To find out the level of nicotine dependence and it correlates among adolescents. SETTINGS AND
DESIGN: A community-based, cross-sectional, observational study was conducted in the Burdwan town, West Bengal, among 1354 adolescent tobacco users.
MATERIALS AND METHODS: Data were collected by direct interview using a pretested, predesigned, semistructured schedule containing the Fagerström Test for Nicotine Dependence (FTND) questionnaire. STATISTICAL ANALYSIS: Pearson's Chi-square test, Student's unpaired t-test, one-way analysis of variance, Pearson's product-moment correlation coefficient, and multivariable linear regression were used. All the statistical analyses were performed using SPSS version 19.0.
RESULTS: The mean FTND score was significantly higher among adolescents aged >15 years, males, Hindu, tobacco users from joint family, who belonged to lower socioeconomic status, who started using tobacco at the age of 10-12 years, using tobacco for ≥5 years, who were not married, were illiterate, working, and not aware of the injurious effect of tobacco to health.
CONCLUSIONS: A suitable individualized approach should be used for those who want to quit tobacco depending on their FTND score.

INTRODUCTION

Excessive use of tobacco in the form of both smoking and smokeless tobacco is an example of modern epidemic and also known as “the brown plague.”[1] According to the estimation of the WHO, tobacco use will cease one billion lives in the 21st century and 80% of that will occur in developing countries.[2] Due to decreased awareness about injurious effect of tobacco among common people, poor literacy, poor socioeconomic status (SES), and less developed de-addiction services, the prevalence of tobacco use is higher among Southeast Asian countries.[3] However, tobacco use increased in developed countries also, due to repeated advertisements by the tobacco company.[4] All these lead to substance abuse among adolescents, leading to economic burden due to a health problem. Tobacco use is also prevalent among Indian adolescents.[56]

The use of tobacco causes temporarily pleasing effect in brain predominantly by altering the mesolimbic pathway.[7] Nicotine is the chief chemical in tobacco, which causes dependence both physical and psychological. The same is also true for smokeless forms of tobacco. Cotinine is a metabolite of nicotine, which is measured in serum/saliva/urine to find the level of nicotine dependence of an individual.[89] However, the test is difficult to perform. Hence, many questionnaires were developed, which act as a surrogate marker of nicotine dependence. One such questionnaire is the Fagerström Test for Nicotine Dependence (FTND). The questionnaire was used on smokers and smokeless tobacco users in different parts of the world, and its reliability is confirmed in a different population.[89] This degree of nicotine dependence will further be helpful in determining the suitable plans for cessation of tobacco use (counseling/pharmacotherapy/both).[7]

Many studies had been carried out previously to find the prevalence of tobacco use among Indians. However, detailed information regarding the prevalence of different levels of nicotine dependence in adolescents is not available in the Indian context. In this background, this study was conducted among adolescent tobacco users of Burdwan town to find out the prevalence of different levels of nicotine dependence among adolescent tobacco users and factors responsible for it.

MATERIALS AND METHODS

A community-based, cross-sectional, observational study was conducted in Burdwan town between January 2016 and December 2018 after taking permission from the institutional ethics committee (vide memo No. BMC/PG/2725). Written informed consent was obtained from the participants/their legal guardians, as applicable. A predesigned, pretested, semistructured schedule was used for collection of data by house-to-house visit. All the current adolescent tobacco users constituted our study population and complete enumeration method is, thus, followed. A total of 1379 adolescent tobacco users were identified and 25 were excluded from the study (1 – seriously ill, 17 – absent despite two home visits, 7 – consent was not available/denied to answer questions). Hence, 1354 adolescent tobacco users were interviewed and they constituted our study population. The interviewer, interviewee, and the data entry operators were not aware of the purpose of the study.

Operational definitions

People who were smoking at the time of the study and had smoked >100 cigarettes in their lifetime were defined as current smokers.[10] The current smokeless tobacco users were defined as people either chewing or snuffing tobacco at the time of the study and either had snuffed or had chewed tobacco more than 20 times in their lifetime.[11] Cigarettes, beedi, cigars, pipes, etc., were considered as smoking products. Cigarette was defined as “any roll of tobacco wrapped in paper or in any substance not containing tobacco.”[12] Beedi contains sun-dried tobacco wrapped with tendu leaf, which does not contain nicotine/tobacco; hence, beedi is also considered as a form of cigarette. Smokeless tobacco products include chewing tobacco and moist/dry snuff. Low, medium, and high levels of nicotine dependence were defined as FTND score <4, 4–6, and >6, respectively.[89] Adolescents were defined as young people aged between 10 and 19 years.

Statistical analysis

All the collected data were entered into Microsoft Excel Worksheet (Microsoft, Redwoods, WA, USA) after double checking. Categorical and continuous data were expressed in proportion and mean values, respectively. The Shapiro–Wilk test was used to test the normality of the data (as n < 2000). Significance of association between two attributes in contingency table was assessed by the Pearson's Chi-square test. The significance of difference between two means was tested by the Student's independent t-test (unpaired), while one-way analysis of variance was used for comparing >2 means. Categorical variables were coded. Degree and direction of relationship between FTND score and different study variables were computed by the Pearson's product moment correlation coefficient (r). Significantly correlated variables were further considered for multivariable linear regression analysis, taking FTND score as dependent variable. P < 0.01 was considered statistically significant. All the statistical analyses were performed using SPSS version 19.0 (Statistical Package for the Social Sciences Inc., Chicago, IL, USA).

RESULTS

The mean age of the study population was 15.9 ± 2.7 years, with majority (60.8%) being >15 years of age. Of the 1354 tobacco users, majority (94.5%) were male, Hindu (97.4%), belonged to joint family (72.4%), and upper-lower SES (54.5%). Forty-eight percent of the tobacco users were exclusively smokers, 27% were using smokeless tobacco exclusively, and 25% were using both. A total of 615 (45.4%) tobacco users belonged to low nicotine dependence group, but 369 (27.3%) were highly dependent to nicotine. The mean FTND score of all tobacco users was 4.2 ± 2.4.

High nicotine dependence was maximally observed among adolescents >15 years of age (92.7%), males (100.0%), Hindu (100.0%), who belonged to joint family (82.1%), lower SES (64.5%), not married (97.6%), educated to primary level (37.9%), working (87.8%), daily tobacco users (100.0%), not aware of the injurious effect of tobacco (95.1%), started using tobacco between 10 and 12 years of age (90.5%), and using tobacco for ≥5 years (95.1%). The mean FTND score was significantly higher among adolescents aged >15 years (5.4 ± 1.9), males (4.3 ± 2.4), Hindu (4.2 ± 2.4), tobacco users of joint family (4.7 ± 2.2), who belonged to lower SES (5.8 ± 2.2), who started using tobacco at the age of 10–12 years (4.5 ± 2.5), using tobacco for ≥5 years (6.3 ± 1.4), who were not married (4.2 ± 2.4), were illiterate (6.9 ± 1.6), working (4.9 ± 2.2), and not aware of the injurious effect of tobacco to health (5.0 ± 2.2). The variation of score observed between different groups is significant statistically [Table 1].

Table 1

Distribution of study population according to the level of nicotine dependence and different variables (n=1354)

There was statistically significant positive correlation of FTND score with age (r = 0.676), male sex (r = 0.185), Hindu religion (r = 0.169), duration of tobacco use (r = 0.893), joint family (r = 0.362), working (r = 0.421), and daily tobacco use (r = 0.798), implying that increase in this variables will increase the FTND score. FTND score is significantly and negatively correlated with starting age of tobacco use (r = − 0.276), SES (r = − 0.528), marital status (r = − 0.061), education (r = − 0.501), and knowledge of injurious effect of tobacco to health (r = − 0.518), implying that increase in this variables will decrease the FTND score.

A linear regression model was generated using FTND score as the dependent variable. Significantly correlated variables in the correlation analysis were further considered for regression analysis. Family type, religion, marital status, and duration of tobacco use, though significantly correlated with FTND score, become insignificant in the regression model. Our model can correctly predict 84.8% variation of the dependent variable, i.e., FTND score [Table 2].

Table 2

Regression coefficients in multivariable linear regression (enter method) taking Fagerström Test for Nicotine Dependence score as dependent variable (n=1354)

DISCUSSION

Tobacco use in the form of both smoking and smokeless tobacco ultimately results in large economic burden to the government due to health-related issue. Our study was conducted to find out the prevalence of different levels of nicotine dependence among adolescents and its correlates. We found that 45.4%, 27.3%, and 27.3% of tobacco users belonged to low, medium, and high dependence group, respectively. High dependence is lower than the findings of Clemente Jiménez et al. (3.3%), which may be due to higher SES of their study population.[13] Saha et al. also noticed a higher prevalence of high nicotine dependence (57.8%) mainly because they included adult tobacco users, and nicotine dependence gradually increases with age.[14] The mean FTND score was 4.2 ± 2.4, which is similar to the findings of Fagerström et al. (2.8–4.6) and Jayakrishnan et al. (5.04 ± 5.05).[1516] However, Saha et al. found a higher score (6.47 ± 2.38), which may be due to inclusion of adult tobacco users.[14]

Similar to the observation of Wu et al., Jayakrishnan et al., and Saha et al., we also found a gradual increase of the FTND score with increase in the age.[141617] The mean FTND score was significantly higher among males (4.3 ± 2.4); Saha et al. also noticed the same, but their finding was not statistically significant (P > 0.05).[14] Roberts et al. found that bad SES was associated with a higher level of nicotine dependence.[18] Our finding was also the same. We observed a gradual decrease in the FTND score with increase in the level of education. Similarly, Schmidt et al. also noted lower education as a risk factor for higher nicotine dependence.[19] Jayakrishnan et al. and Wu et al. both noted an increase in the score in the college students, which is contrary to our findings.[1617] This may be due to very few number of college students in our study. We found a higher score among working adolescents (4.9 ± 2.2), which is also supported by the observation of Jayakrishnan et al.[16] and Ota et al.[20] However, contrary to our study, Schmidt et al. noticed a lower level of nicotine dependence among working people.[19] Similar to the observation of Schmidt et al., we also noticed a higher level of nicotine dependence among unmarried.[19] However, contrary to our finding, Wu et al. and Saha et al. noticed a higher FTND score among married individuals.[1417] This variation may be due to less number of married people in our study. Similar to the findings of the present study, Roberts et al.,[18] Breslau et al.,[21] and Taioli and Wynder[22] also found that initiation of tobacco use at an early age and using tobacco for longer duration were significant risk factors for high level of nicotine dependence. Similar to the finding of Saha et al., we also observed that FTND score was higher among daily users (5.8 ± 1.7) and who were not aware of the injurious effect of tobacco on health (5.0 ± 2.2).[14] Our model can correctly predict 84.8% variation of the FTND score, while Saha et al. can only predict 27.3%.[14]

CONCLUSIONS

It is clear that tobacco use and dependence to nicotine had its origin at adolescence and hence school children should be targeted and made aware of injurious effect of tobacco to health. Their parents and teachers should actively be involved. Advertisements against the use of tobacco should be done in TV/newspapers/radio to prevent nicotine dependence. “Get ready for plain packaging,” the slogan for World No-tobacco Day (2016), should be given due importance.[13] Suitable plans should be developed for those who want to quit tobacco depending on their nicotine dependence.[7] Although this study contains an appropriate sample size, for development of appropriate plans, multicentric studies should be undertaken. As the study was conducted in urban area, it may not reflect the rural scenario.

Financial support and sponsorship

The first author received ICMR STS.

Conflicts of interest

There are no conflicts of interest.