A Comparative Study on the Health Problems and Substance Abuse among the Tobacco Farmers and Non-Tobacco Farmers in Hassan District, Karnataka.

BACKGROUND AND AIMS: India ranks third in the worldwide tobacco production (2017), and it is increasing every year. Hassan is an important tobacco growing district in Karnataka with over 12,000 growers. These growers are exposed to health risks during cultivation of tobacco, pesticide exposure, long duration of work, mental stress, and nicotine toxicity - Green Tobacco Sickness (GTS) due to direct handling of green tobacco leaves.
OBJECTIVES: To determine the prevalence of health problems associated with tobacco farming. To determine the extent of substance abuse in tobacco farmers as compared to non-tobacco farmers. METHODOLOGY STUDY
DESIGN: Cross-sectional study. DURATION: 3 months. SAMPLING TECHNIQUE: 30 × 7 Cluster sampling technique. House-to-house survey was conducted in 30 tobacco growing villages of Hassan. Seven tobacco growers and seven non-growers were interviewed in each village. Alcohol use disorder identification test (AUDIT) & Fagerstrom nicotine dependence (FND) scale was used to assess the extent of substance abuse.
RESULTS: Symptoms of GTS like nausea, dizziness, poor appetite, insomnia were reported more in tobacco growers (p < 0.01). On FND assessment, 63% had moderate to high dependence. On AUDIT assessment, 55.07% growers who had drinking habit had hazardous drinking behavior. Logit function model was used to assess parameter estimate (OR) on substance abuse.
CONCLUSION: Lack of knowledge regarding health effects of tobacco farming, lack of use of PPE, dust and smoke exposure during curing, intense physical and mental stress maybe some reasons for health problems in tobacco growers. Copyright:

INTRODUCTION

During the past decades, tobacco farming has shifted from the developed countries to developing countries as farmers are lured by its economic gains.[1] The land cultivated for tobacco and its production has increased steadily over the past few years. In 2017, India had a production of 799,960 tons of tobacco and ranked third in worldwide tobacco production.[2]

Tobacco growers are exposed to various health risks, which can have long term consequences. Apart from this, there are environment and social impacts. The health effects of tobacco production include nicotine poisoning (green tobacco sickness), effects of pesticide exposure, respiratory effects, musculoskeletal, other injuries and chronic diseases.[3] Green Tobacco Sickness (GTS) is acute nicotine poisoning due to the transdermal absorption of nicotine which occurs through contact with the green tobacco leaves during planting, cultivating, harvesting and curing. This poisoning is intensified at the time of harvest, because they are manually collected and loaded close to the body. The diagnosis is made using the harvesting tobacco history and the presence of signs and symptoms such as nausea, vomiting, weakness, dizziness, headache, abdominal cramps, chills, blood pressure, and heart rate fluctuation.[4] GTS has been described among farmers and farmworkers in different regions of the US, Brazil, China, Japan, India, and Italy. Pesticides used may also lead to acute and chronic intoxication, which present clinically as muscle spasms, convulsions, nausea, fainting, vomiting, diarrhea, and breathing difficulties.[4] According to Parekh et al. study conducted in Gujarat, the prevalence of GTS was found to be 47%.[5]

Hassan is an important tobacco growing district in Karnataka with over 12,000 growers as per the information obtained from the Tobacco board. Unlicensed tobacco farming is also being carried out, as the farmers are attracted by the huge profits it can offer. The effects of tobacco consumption are well known and well documented, but the health effects and other hazards of tobacco during its cultivation and processing are hardly studied. Therefore, this study was undertaken to study the impact of tobacco farming on the health of tobacco farmers, their willingness to quit tobacco farming and feasibility of an alternative crop.

OBJECTIVES

To determine the prevalence of health problems associated with tobacco farming.

To determine the extent of substance abuse in tobacco growers as compared to non- growers.

METHODOLOGY

Study design

Cross Sectional study.

Study period

May 2019- July 2019 (3 months)

Study setting

Tobacco growing villages of Arkalagud and Holenarsipura taluks which are the main tobacco cultivating taluks of Hassan district. The following 30 villages from Arkalagud and Holenarsipura were included in the study:

Arkalgud Taluk

Harlahalli, Kotwal, Madihally, Ramanakoppalu, Siridhanahalli, Bannur, K.Abbur, M.G. Hosur, Konnanur, Lakkanahaly, Heggathur, Keregodu, Bilaguli, Mudugganur, Sabbathi

Holenarsipura Taluk

Bediganahalli, Malliganahalli, Hadya, Hallymysore, Malanaikanahalli, Nagganahalli, Gohalli, Doddahally, Nerale, Dalegowdanahalli, Badakyathanahalli, Motanaiyakanahally, Tejur, Kuppe, Kallahaly

Sampling technique

30 × 7 Cluster sampling technique

Sample size estimation

According to prevalence of GTS in Cargnin M C et al. study (2012)[4]

P = 67% taking allowable error as d = 10% z = 1.96

Sample size = z2 pq/d2 = 4 × 67 × 33/(6.7) 2 = 197 farmers

The sample size according to the above sampling is 210 tobacco growers and 210 non tobacco growers

Hence adequate.

Sampling process

There were two separate (30 × 7) clusters of tobacco growers and non – growers taken for the purpose of comparison [Figure 1].

Figure 1

Sampling process

The list of the villages where tobacco growing is undertaken were obtained from the Tobacco board along with the number of tobacco farmers in these villages.

The villages in both Arkalagud and Holenarsipura taluk were arranged starting from the village with the highest number of tobacco growers.

15 villages from each taluk was selected from this sampling frame by systematic random sampling

7 tobacco growers and 7 non tobacco growers were interviewed in each village.

The first house to be interviewed in each village were randomly selected by using the last digit of the number on currency note.

METHOD

The study was done after obtaining clearance from Institutional Ethical Committee (IEC/HIMS/RR72/21-05-2019). 212 tobacco growers and 210 non-growers were interviewed from 30 tobacco growing villages of Hassan. The head of the family of the selected households were interviewed regarding their health problems and substance abuse after obtaining their consent.

Interview was conducted using a predesigned, pre-tested, structured questionnaire which measured 11 symptoms generally associated with GTS. Furthermore, chronic illness like Bronchial asthma, hypertension, Diabetes mellitus or any chronic respiratory illness or other illness. Self-reported illness of the study subject with respect to these 11 symptoms of GTS in the last one year period were recorded along with its frequency ranging from never to more than thrice a week.

As the symptoms of GTS were non-specific, they were compared with its occurrence among other farmers (non- tobacco growers) using the same questionnaire. Assessment for substance abuse was done using Fagerstrom nicotine dependence (FND) scale and Alcohol Use Disorder identification test (AUDIT).

The Fagerstrom Scale was used in smoking farmers to assess the nicotine dependence.[6]

This scale contains 6 questions with scores ranging from 0-10 points, which when summed allows for the estimation of the degree of nicotine dependence

0points = no dependence

1-2 = very low dependence

3-4 points = low dependence

5-7 points = medium dependency

8-10 points = very high dependence

Alcohol use was assessed in farmers who consume alcohol using AUDIT. AUDIT is a 10-item screening tool developed by the World Health Organization (WHO) in 2001, to assess alcohol consumption, drinking behaviors, and alcohol-related problems. It is an effective screening tool in primary care settings. A score of 8 or more is considered as hazardous or harmful alcohol use. The AUDIT has been validated across genders and in a wide range of racial/ethnic groups.[7]

Ethical clearance

Ethical approval for this study (Ethical Committee IEC/HIMS/RR72/21-05-2019) was provided by the Institutional Ethics Committee, HIMS, Hassan, Karnataka, India on 21 May 2019.

Statistical analysis

Descriptive and inferential statistics were carried out using using SPSS software version 22.0. Chi- square test and Fischer exact test was used to test the significance of association between tobacco growing and the health problems or substance abuse. The means of Fagerstrom and AUDIT score among growers and non- growers were compared using z test. A value of P < 0.05 was considered as significant.

Inclusion criteria

Farmers (head of the family) who have cultivated tobacco in the previous year and presently continuing it.

Exclusion criteria

Individuals not consenting to participate in the study.

RESULTS

Highest number of growers (45.3%) and non – growers (38.6%) were in the 40 – 54 years age group and majority of them had poor education status. Growers had comparatively poorer education status as compared to non-growers and the difference was statistically significant (P < 0.0001). Significantly higher proportion of growers belonged to joint families and 3 generation as compared to non-growers (P = 0.001) [Table 1].

Table 1

Socio- demographic characteristics of the respondents

	Growersn (%)	Non- Growersn (%)	p
AGE DISTRIBUTION		0.295
24- 39	51(24.1)	51(24.3)
40-54	96 (45.3 )	81(38.6)
55-69	65 (30.7)	78(37.1)
EDUCATION
Illiterate	42 (19.8)	60 (28.6)	*<0.000
Upto 10th Std	131 (61.8)	75 (35.7)
>10th Std	39 (18.4)	75 (35.7)
TYPE OF FAMILY
Nuclear	117 (54.9)	151(71.9)	*0.001
Joint	58 (27.2)	33(15.7)
Three generation	37(17.4)	26(12.4)
Total	212(100)	210(100)

*P < 0.05 – significant

The mean years of farming of growers was 23.86 ± 11.28 years with total area used for farming 3.60 ± 3.12 acres. Among non-tobacco growers, the mean years of farming was 27.15 ± 12.86 years, while total area used for farming was 2.73 ± 1.792 acres.

As seen from Table 2, the highest reported symptoms were tiredness (68.5%), dizziness (49.1%) and headache (43.9%). Tiredness and insomnia was experienced by farmers more than three times a week (8.9% & 8.5% farmers, respectively)

Table 2

Symptoms of Green Tobacco Sickness and frequency of its occurrence as reported by the Tobacco growers

Symptoms of Green Tobacco Sickness (GTS)	≥3 times /week n (%)	1-2 times/week n (%)	1-2 times/month n (%)	Rarely n (%)	Total n (%)
Tiredness	19 (8.9)	32 (15.1)	70 (33.1)	25 (11.8)	146 (68.6)
Nausea	6 (2.8)	11 (5.2)	12 (5.7)	5 (2.4)	34 (16)
Dizziness	9 (4.2)	30 (14.2)	49 (23.1)	16 (7.5)	104 (49.1)
Poor Appetite	10 (4.7)	10 (4.7)	18 (8.5)	0 (0)	38 (17.9)
Headache	3 (1.4)	28 (13.3)	39 (18.6)	23 (10.9)	93 (43.9)
Insomnia	18 (8.5)	13 (6.1)	12 (5.7)	10 (4.7)	53 (24.9)
Breathlessness	7 (3.3)	8 (3.8)	14 (6.6)	10 (4.7)	39 (18.4)
Increased salivation	5 (2.4)	1 (0.5)	3 (1.4)	5 (2.4)	14 (6.6)
Increased sweating	11 (5.2)	11 (5.2)	21 (9.9)	11 (5.2)	54 (25.5)

Table 3 shows the percentage of respondents who reported they had ever experienced these 11 symptoms of GTS during the last one year. The prevalence of all 11 symptoms among tobacco growing farmers was higher than that of non- tobacco farmers. Complaints of nausea, dizziness, Poor appetite, insomnia, breathlessness, increased sweating, increased heart rate, increased salivation, poor appetite, itchiness and rashes were reported more in the tobacco growers (p < 0.01). Musculoskeletal pain, chronic respiratory illness and other chronic illness like Diabetes Mellitus and hypertension were reported higher in growers than in non-growers. However, the difference was not statistically significant (P > 0.05). Substance abuse was reported more in growers (58.5%) than in non-growers (53.3%). However, the difference was not statistically significant.

Table 3

Occurrence of illness among tobacco growers versus non - growers

Symptoms of Green Tobacco Sickness (GTS)	Growersn (%)	Non-Growersn (%)	p
Tiredness	146 (68.55)	133 (63.3)	0.216
Nausea **	34 (15.96)	12 (5.71)	0.001
Dizziness**	104 (48.82)	12 (5.71)	0.000
Palpitation *	37 (17.45)	19 (9.04)	0.013
Increased salivation **	14 (6.6)	2 (0.9)	0.004
Headache	104 (49.05)	93 (44.28)	0.376
Poor Appetite **	38 (17.83)	16 (7.61)	0.002
Insomnia**	53 (24.87)	28 (13.33)	0.003
Breathlessness **	39 (18.31)	19 (9.04)	0.007
Increased sweating **	54 (25.34)	24 (11.42)	0.000
Itching	25 (11.79)	24 (11.42)	0.879
Other health problems
Musculoskeletal pain	168 (78.87)	179 (85.23)	0.117
Chronic Respiratory illness	44 (20.9)	27 (12.86)	0.232
Other Chronic Diseases - HTN, DM, IHD (NCDs)	45 (21.22)	35 (16.67)	0.088

**p < 0.001 * p < 0.01

Table 4 and Table 5 shows, on interpreting the scores of Fagerstrom Nicotine Dependence scale, 100% growers had some form of dependence on nicotine whereas only 89.5% of non- growers were nicotine dependent. 26.9% growers had high dependence on nicotine. The difference was statistically significant (p = 0.003) [Figure 2].

Table 4

Prevalence of substance abuse in the farmers

	Growersn (%)	Non Growersn (%)	p
Substance abuse (Any form)	124 (58.5)	112 (53.33)	0.286
a. Smoking	108 (51.42)	104 (50)	0.626
b. Alcohol	69 (32.54)	82 (39.05)	0.212
c. Tobacco/ beetle nut chewing	7 (3.3)	4 (1.9)	0.351
*Total	212 (100)	210 (100)

*Multiple responses were considered

Table 5

Assessment of extent of substance abuse

Substance abuse	Growersn (%)	Non-Growers n (%)	p
Assessment of Nicotine Dependence based on Fagerstrom Nicotine Dependence test
No Dependence	0 (0)	11 (10.5)	0.003*
Low (score 1-2)	21 (19.4)	11 (10.5)
Low-moderate (score 3-4)	19 (17.6)	24 (22.9)
Moderate (score 5-7)	39 (36.1)	35 (33.3)
High (score > 8)	29 (26.9)	23 (21.9)
Total	108 (100)	105 (100)
Assessment of drinking behavior based on AUDIT Score
Non-hazardous drinking ( < 8)	31 (43.48)	26 (31.71)	0.106
Hazardous drinking (≥8 )	38 (55.07)	55 (68.75)
Total	69 (100)	82 (100)

*p < 0.05 – significant

Figure 2

Nicotine dependence among farmers. (Based on Fagerstrom Nicotine Dependence test)

The mean nicotine dependence score for growers was 5.17 ± 2.87 and median score was six whereas for non- growers mean was 5.12 ± 2.89 and median score five. On calculating, the z – score was found to be 0.22 and P – value was 0.825 which was not significant.

Hazardous drinking habit was higher in non- growers (p = 0.106). The mean AUDIT score for growers was 9.96 ± 6.553 and for non-growers was 13.21 ± 14.27. The z-score was found to be 1.472 and P –value was 0.141.

From the Table 6, the proportionate change in odds in the OR was noticed among predictor variables in tobacco growers and non-tobacco growers. In Fagerstrom and AUDIT scale model -Odds Ratio were less than one (i.e. protective effect) shown among the predictors (duration of working in farms and area utilized for farming) increases, the odds of the outcome (substance abuse-smoking and alcoholism) occurring decreases.

Table 6

Parameter Estimates for Tobacco Growers and Non-Growers (Fagerstrom and AUDIT scale)

Parameters	Odds Ratio	95% CILower	95% CIUpper
Education (FG/G)1	1.519	1.182	1.952
Farming years	0.882	0.702	1.109
Farming area	0.976	0.897	1.061
Education (Audit/G)2	1.118	0.849	1.474
Farming years	0.93	0.715	1.210
Farming area	1.22	1.016	1.470
Education (FG/NG)3	1.606	1.223	2.11
Farming years	0.917	0.74	1.13
Farming area	1.017	0.86	1.19
Education (Audit/NG)4	1.59	1.18	2.143
Farming years	0.95	0.76	1.18
Farming area	0.94	0.79	1.11

Note: 1. Fagerstrom scale in growers; 2. AUDIT scale in growers; 3. Fagerstrom scale in Non-growers and 4. AUDIT scale in Non-growers

DISCUSSION

A comparative study was done to assess the health of tobacco growers and non-tobacco growers and the presence of substance abuse in them. 212 tobacco growers and 210 non-growers were interviewed from 30 villages of Holenarsipura and Arkalgud taluks. The prevalence of symptoms of Green Tobacco Sickness was in the range of 6.57% to 68.5% and the most frequent symptom were tiredness and insomnia, which were reported more than three times a week in 8% of the subjects. As the symptoms of GTS were non-specific, presence of these symptoms were compared with non-tobacco farmers and the difference was found to be significant (p < 0.01). Complaints of nausea, dizziness, poor appetite, insomnia, breathlessness, increased sweating, increased heart rate, increased salivation, and poor appetite were reported more in the tobacco growers (p < 0.01). Tiredness, headache and musculoskeletal problems was reported by a majority in both the groups of farmers.

Similarly, in 2005, Parikh JR et al. had conducted a case control study on 685 exposed and 655 control workers in villages of Anand district in Gujarat and found the overall prevalence of GTS to be 47% which is similar to the present study finding.[5]

Some studies were also conducted outside India. According to a study by Cargnin M C et al. in 2012, undertaken in Brazil, the prevalence of green tobacco sickness was 67%; 25% had heart and respiratory disease. 64.7% smokers among tobacco farmers reported low dependence on nicotine.[4] In the study conducted by Nguyen TH et al. in Vietnam in 2009, it was found that tobacco growers had significantly higher proportion of symptoms of GTS as compared to non-growers.[8]

In the present study, on the assessment for substance abuse, growers were found to have more substance use. 63% of tobacco growers had moderate to high dependence (p = 0.003). On AUDIT assessment, it was found that among farmers with drinking habit, 55.07% growers and 68.75% of non - growers had hazardous/risky drinking behavior. Level of education, area under farming and duration of farming were found to be factors that influenced their substance abuse.

On comparing with the general population of Hassan, the proportion of tobacco farmers who smoked (55.19%) was found to be much higher (19.8% as per DLHS-4).32.08% Growers interviewed consumed alcohol while as per DLHS-4, alcohol consumers in Hassan were only 16.3%.

There was therefore a significant higher occurrence of illness in tobacco growers due to Green Tobacco Sickness as found through this study. They are also exposed to the innumerable harmful consequences of stress and the intense physical work demands of tobacco cultivation. Smoking and other substance abuse may be due to this stress and it is higher than the general population.

This study conducted on a large number of farmers gave some important findings regarding health of tobacco growers. Only a few similar studies were conducted so far. However, self- reported illness of the farmers were considered and data regarding previous one year were asked hence possibility of recall bias was present.

In 2003, the World Health Organization (WHO) adopted the Framework Convention on Tobacco Control (WHO FCTC) – a global treaty in response to the tobacco epidemic which specially addresses the health and environmental risks associated with tobacco farming. To reduce these consequences, it stresses on the provision of 'support for economically viable alternative activities' for tobacco growers to reduce its production without adversely affecting their livelihood. Owing to the health risks due to tobacco growing and the effects consumption of tobacco, finding an alternate crop is the need of the hour.[910]

Recommendations

Tobacco growers need to be made aware of the health hazards they are at a risk of during tobacco farming.

Use of Personal protective equipment (PPE) should be taught and its importance should be emphasized. There should be a provision of supply of PPE at free of cost.

Finding an alternative crop for tobacco farmers which is economically viable.

Financial support and sponsorship

The study was funded by State Anti- Tobacco Cell through District Tobacco Control Cell, Hassan

Conflicts of interest

There are no conflicts of interest.