Prevalence and health risk score of tobacco and alcohol use by using the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test among construction workers in Puducherry, India.

BACKGROUND: Construction workers are one of the important neglected occupation groups. The study aimed to assess the prevalence and health risk score of tobacco and alcohol use and its association with sociodemographic factors and self-reported morbidities among construction workers.
MATERIALS AND METHODS: A cross-sectional study was conducted among 400 male construction workers in a tertiary care medical institution in Puducherry, India. A semi-structured questionnaire based on the World Health Organization Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) guidelines for assessment and health risk score of alcohol and tobacco use was used. The association of current tobacco and alcohol use with associated factors was analyzed by univariate analysis.
RESULTS: About 371 male construction workers participated. The mean (standard deviation) age of construction workers was 28.28 (9.04) years. The prevalence of current tobacco and alcohol use was 60.1% (223/371) and 47.7% (177/371), respectively. Out of 133 smokers, 60.9% (81) were used only bidi, 27.1% (36) only cigarette, and 12% (16) both bidi and cigarette. Most of the workers (126/151 [83.4%]) used khaini among smokeless tobacco users. The majority (204/241 [84.6%]) of ever smokers and nearly half of alcohol users (103 [49.8%]) had moderate risk based on ASSIST score. Higher current tobacco consumption is associated with higher age group, married, lower education status, unskilled occupation, contractual workers, migrants from other states, more duration of work in construction field, and the presence of self-reported health problems (P < 0.05). Current alcohol consumption is associated with more duration of work in construction field and the presence of self-reported health problems (P < 0.05).
CONCLUSIONS: Tobacco and alcohol use is high, and health risk due to substance use is also more in construction workers. Copyright:

In India, construction workers and their health priority are an important concern for its stakeholders.[1] At present, more than 20 million construction workers working in different states in India. The working pattern, absence of recreational activity, and accompany of friends or peer pressure force them to indulge in substance abusive activities. In view of the above, tobacco and alcohol use is an important health issue to be considered, especially in neglected occupation groups like construction workers.

India is the second largest consumer of tobacco product and the third larger producer of tobacco globally. As per the survey report of the Global Adult Tobacco Survey, 35% of total adults in India consume tobacco substances, out of which 21% of adults use only smokeless tobacco, 9% only smoke tobacco products, and 5% use tobacco in any other form either smoking or chewing or both.[2] According to the Global Status Report on Alcohol and Health (2014), around 30% of the adult population of India consume alcohol.[3] However, notable differences in smoking and alcohol use rates are seen across population groups, and significantly higher tobacco consumption rates have been found among construction workers.[4] As far as alcohol consumption is concerned, Puducherry and Tamil Nadu are leading in the top of the list in the country.[5] However, there is a paucity of studies from India in comparing the prevalence of tobacco and alcohol use and its health risk in construction workers. Therefore, this study aimed to assess the prevalence of tobacco and alcohol use and its association with sociodemographic factors and self-reported morbidities among construction workers.

MATERIALS AND METHODS

Study design and setting

A cross-sectional study was conducted from July to December 2017 among male construction workers working under Larsen & Toubro (L&T) Company in a tertiary care medical institution in Puducherry, India.

Sample size calculation and sampling technique

The sample size was calculated based on the prevalence of tobacco and alcohol use reported among construction workers. The sample size was calculated taking prevalence as 32.2% and 60.1% of alcohol and tobacco use, respectively,[6] among construction workers. With 5% absolute precision, the sample size was 336 for alcohol use and 369 for tobacco use. Hence, the sample size for this study was taken as 369. After adding a nonresponse rate of 8%, total sample size became 400. There were 400 construction workers working in the company in this tertiary care institute, Puducherry, and all of them were included in the study.

Study procedure

Prior to the study, written permission from the L&T Company authorities was obtained. The data were collected by a single investigator by using a predesigned, pretested, semi-structured questionnaire which included sociodemographic details, history of current tobacco and alcohol use, the reasons for initiating tobacco and alcohol use, and self-reported comorbidities. The questionnaire was prepared based on the World Health Organization (WHO) Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) instrument guidelines for alcohol and tobacco use. The severity and health risk of tobacco and alcohol was assessed by the WHO-ASSIST, which was used at primary health-care level.[7] This questionnaire was developed by the WHO and an international team of substance use researchers as a simple method of screening for hazardous, harmful, and dependent use of alcohol, tobacco, and other psychoactive substances. The ASSIST is specially designed for use by health-care workers in a health-care setting. Linguistic validation was done for self-prepared questionnaire by translating the questionnaire into Tamil, Hindi, Bengali, and Oriya by two bilinguistic persons separately.

For construction workers who were residing within the campus, the interview was conducted in their residential area during the evening time. The interview was conducted at the in construction sites for those who are staying outside the campus. Those who were found to be having tobacco and alcohol use were given health education by the investigator at the site itself. If any tobacco- and alcohol-addicted subjects were found, they were referred to the psychiatry outpatient department or de-addiction ward. The results were debriefed, and group counseling was given to the participants at the end of the study.

Operational definitions

Current tobacco and alcohol users: It was defined based on ASSIST questionnaire classification which mentions the risk of substance use in the last 3-month period preceding the interview (tobacco and alcohol use). Ever tobacco and alcohol users: Use of tobacco and alcohol ever in a lifetime.

Ethical issues

The study was approved by the Postgraduate Research Monitoring Committee and Institutional Ethical Committee of the medical institution. Written informed consent was obtained from all the participants in local language. They were assured regarding the disclosure of their identity and confidentiality of data generated from the study. In our study, participants were from the different states of India and informed consent form was translated in their language (Hindi, Bengali, Oriya, and Tamil) and freedom to withdraw from the study at any time during the interview or examination was also explained prior to taking of the informed consent.

Statistical analysis

Data entry was done by using EpiData version 3.1 (EpiData Association, Odense, Denmark) and analyzed by the Statistical Package for the Social Sciences (SPSS) version 19.0 (IBM PASW Statistics, Country Office Bangalore, Karnataka, India). The tobacco and alcohol use among construction workers was expressed as proportion with 95% confidence interval. The association of current tobacco and alcohol use with sociodemographic, self-reported health problem and other variables was tested using Chi-square test. P < 0.05 was considered statistically significant.

RESULTS

About 371 male construction workers participated with a response rate of 92.8%. The mean (standard deviation [SD]) age of the construction workers was found to be 28.28 (9.04) years. Most of them (265 [71.4%]) were belonged to 18–30 years of age group. Almost equal participation was present in married (195 [52.6%]) and unmarried (176 [46.6%]) category. Most of the participants (247 [66.6%]) had studied up to class 10th class [Table 1].

Table 1

Distribution of sociodemographic characteristics of workers (n=371)

Characteristics	n (%)
Age group (years)
18-30	265 (71.4)
31-45	82 (22.1)
46 and above	24 (6.5)
Marital status
Unmarried	176 (47.4)
Married	195 (52.6)
Education
No formal education	40 (10.8)
1-10th	247 (66.6)
>10th	84 (22.6)
Socioeconomic class* (per capita monthly income in rupees)
Class I (≥6254)	38 (10.2)
Class II (3127-6253)	120 (32.3)
Class III (1876-3126)	125 (33.7)
Class IV (938-1875)	88 (23.7)
State of origin
Puducherry and Tamil Nadu	84 (22.6)
West Bengal	122 (32.9)
Jharkhand	44 (11.9)
Odisha	37 (10.0)
Chhattisgarh	22 (5.9)
Bihar	27 (7.3)
Others**	35 (9.4)
Type of workers
Contractual	332 (89.5)
Permanent	39 (10.5)
Occupation
Unskilled	251 (67.7)
Semiskilled	79 (21.3)
Skilled	41 (11.1)
Duration of work in construction field (years)
Up to 1	95 (25.6)
1-5	115 (31.0)
6-10	99 (26.7)
>10	62 (16.7)
Duration of work in current place (years)
Up to 1	314 (84.6)
1-5	45 (12.1)
>5-10	12 (3.2)

*According to modified BG Prasad’s Classification, January 2017; **Uttar Pradesh, Madhya Pradesh, Kerala, Assam

About two-third of them were currently using either tobacco or alcohol. The prevalence of current tobacco and alcohol use was 60.1% (223/371) and 47.7% (177/371), respectively [Table 2].

Table 2

Prevalence of substance use among construction workers (n=371)

Substance use	Current user, n (%)	Ever user, n (%)
Any substance use (alcohol or tobacco)	251 (67.7)	272 (73.3)
Tobacco use	223 (60.1)	241 (65.0)
Only smoking	72 (19.4)	82 (22.3)
Only Smokeless	90 (24.2)	68 (18.3)
Both	61 (16.5)	91 (24.5)
Alcohol use	177 (47.7)	207 (55.8)
Only alcohol use	49 (13.2)	31 (8.3)
Both alcohol and tobacco use	128 (34.5)	176 (47.4)

Out of 133 smokers, 60.9% (81) were used only bidi, 27.1% (36) only cigarette, and 12% (16) both bidi and cigarette, respectively. Most of the workers (126/151 [83.4%]) used khaini among smokeless tobacco users [Table 3].

Table 3

Types of tobacco products used among current tobacco users

Types of products	n (%)
Smokers (n=133)
Bidi	81 (60.9)
Cigarette	36 (27.1)
Both bidi and cigarette	16 (12)
Smokeless (n=151)
Khaini	126 (83.4)
Gutkha	4 (2.6)
Both gutkha and khaini	21 (13.9)

The majority (204/241 [84.6%]) of ever smokers were found to possess moderate risk. Nearly half of the alcohol use participants (103 [49.8%]) were under moderate risk and 46.4% (96) had low risk based on ASSIST score [Table 4].

Table 4

Level of health risk in tobacco and alcohol use among ever tobacco and alcohol users based on the Alcohol, Smoking and Substance Involvement Screening Test score

	n (%)
Health risk in tobacco use (n=241)
Low risk (0-3)	19 (7.9)
Moderate risk (4-26)	204 (84.6)
High risk (27 and more)	18 (7.5)
Health risk in alcohol use (n=207)
Low risk (0-10)	96 (46.4)
Moderate risk (11-26)	103 (49.8)
High risk (27 and more)	8 (3.9)

The mean (SD) age of initiation of smoking was 19.5 (SD, 5.96) years and smokeless tobacco use was 19.5(SD, 6.95) years. The mean age of initiation of alcohol was 21.2 (SD, 5.5) years. Among smokers, smokeless users, and alcohol users, the most common cause of initiation was peer pressure in 138 (79.7%), 130 (81.7%), and 128 (61.8%) participants respectively. Stress was found to be the second common reason for initiation, which was reported by 21 (12.1%) smokers and 9 (5.7%) smokeless tobacco users, while among ever alcohol users, the second most common cause was the social cause (48 [23.1%]).

The proportion of workers with tobacco users increases with age group. The proportion of tobacco consumption is more in married compared to unmarried participants. Tobacco consumption decreases with an increase in education status. Tobacco consumption decreases with an increase in socioeconomic status in our study. The proportion of tobacco consumption is highest in the unskilled type of occupation (66.1%). The proportion of tobacco consumption is more in contractual workers when compared to the permanent workers. Tobacco consumption is more among participants from other than Puducherry and Tamil Nadu which is statistically significant. Among all the participants, about 37 (10%) had self-reported any type of illness [Table 5].

Table 5

Association of current tobacco use with sociodemographic factors and self-reported health problem (n=371)

Variables	Tobacco		χ 2	P
	Yes (n=223), n (%)	No (n=148), n (%)
Age (years)
18-30	146 (55.1)	119 (44.9)	11.201	0.004*
31-45	57 (69.5)	25 (30.5)
46-60	20 (83.3)	4 (16.7)
Marital status
Unmarried	90 (51.1)	86 (48.9)	11.240	0.001*
Married	133 (68.3)	62 (31.8)
Type of family
Nuclear	146 (62.1)	89 (37.9)	1.091	0.296
Joint/extended	77 (56.6)	59 (43.4)
Education
No formal education	35 (87.5)	5 (12.5)	28.426	<0.001**
1-10	155 (62.8)	92 (37.2)
>10	33 (39.3)	51 (60.7)
Socioeconomic class
Class I	17 (44.7)	21 (55.3)	7.003	0.072
Class II	68 (56.7)	52 (43.3)
Class III	78 (62.4)	47 (37.6)
Class IV	60 (68.2)	28 (31.8)
Occupation
Unskilled	166 (66.1)	85 (33.9)	16.390	<0.001**
Semi-skilled	43 (54.4)	36 (45.6)
Skilled	14 (34.1)	27 (65.9)
Type of workers
Contractual	206 (62.0)	126 (38.0)	4.959	0.026*
Permanent	17 (43.6)	22 (56.4)
State of origin
Puducherry and Tamil Nadu	37 (44.0)	47 (56.0)
West Bengal	85 (69.7)	37 (30.3)	15.322	0.018*
Jharkhand	30 (68.2)	14 (31.8)
Odisha	23 (62.2)	14 (37.8)
Chhattisgarh	13 (59.1)	9 (40.9)
Bihar	15 (55.6)	12 (44.4)
Others	20 (57.1)	15 (42.9)
Duration of work in construction field (years)
Up to 1	53 (55.8)	42 (44.2)	11.614	0.009*
1-5	58 (50.4)	57 (49.6)
5-10	67 (67.7)	32 (32.3)
>10	45 (72.6)	17 (27.4)
Duration of work in current place (years)
Up to 1	190 (60.5)	124 (39.5)	1.992	0.369
1-5	24 (53.3)	21 (46.7)
5-10	9 (75.0)	3 (25.0)
Self-reported health problem
Yes	30 (81.1)	7 (18.9)	7.539	0.006*
No	193 (57.8)	141 (42.2)
Type of self-reported health problem
Musculoskeletal	8 (88.9)	1 (11.1)	14.620	0.012*
Skin problems	8 (88.9)	1 (11.1)
Hypertension/diabetes	2 (50.0)	2 (50.0)
Respiratory	2 (40.0)	3 (60.0)
Others**	10 (100.0)	0
No comorbidities	193 (57.8)	141 (42.2)

*Chi-square test used for analysis and P<0.05 was considered statistically significant; **Renal stone (2) + piles (2) + chronic headache (3) + dental carries (2) + hydrocele (1)

The proportion of workers with alcohol consumption is more among those from Puducherry and Tamil Nadu (54.8%) which is higher when compared to other states. About 61.1% of participants with 5–10 years of duration of work in construction field currently use alcohol [Table 6].

Table 6

Association of current alcohol use with sociodemographic and self-reported health problem (n=371)

Variables	Alcohol		χ 2	P
	Yes (n=177), n (%)	No (n=194), n (%)
Age (years)
18-30	117 (44.2)	148 (55.8)	5.139	0.077
31-45	45 (54.9)	37 (45.1)
46-60	15 (62.5)	9 (37.5)
Marital status
Unmarried	75 (42.6)	101 (57.4)	3.485	0.062
Married	102 (52.3)	93 (47.7)
Type of family
Nuclear	116 (49.4)	119 (50.6)	0.702	0.402
Joint/extended	61 (44.9)	75 (55.1)
Education
No formal education	21 (52.5)	19 (47.5)	1.236	0.539
1-10	120 (48.6)	127 (51.4)
>10	36 (42.9)	48 (57.1)
Socioeconomic class
Class I	19 (50.0)	19 (50.0)	0.622	0.891
Class II	54 (45.0)	66 (55.0)
Class III	60 (48.0)	65 (52.0)
Class IV	44 (50.0)	44 (50.0)
Occupation
Unskilled	123 (49.0)	128 (51.0)	3.463	0.177
Semi-skilled	40 (50.6)	39 (49.4)
Skilled	14 (34.1)	27 (65.9)
Type of workers
Contractual	161 (48.5)	171 (51.5)	0.780	0.377
Permanent	16 (41.0)	23 (59.0)
State of origin
Puducherry and Tamil Nadu	46 (54.8)	38 (45.2)
West Bengal	62 (50.8)	60 (49.2)	9.691	0.138
Jharkhand	20 (45.5)	24 (54.5)
Odisha	17 (45.9)	20 (54.1)
Chhattisgarh	11 (50.0)	11 (50.0)
Bihar	6 (22.2)	21 (77.8)
Others	15 (42.9)	20 (57.1)
Duration of work in construction field (years)
Up to 1	33 (34.7)	62 (65.3)	18.904	<0.001*
1-5	47 (40.9)	68 (59.1)
5-10	61 (61.6)	38 (38.4)
>10	36 (58.1)	26 (41.9)
Duration of work in current place (years)
Up to 1	141 (44.9)	173 (55.1)	7.297	0.026*
1-5	27 (60.0)	18 (40.0)
5-10	9 (75.0)	3 (25.0)
Self-reported health problem
Yes	24 (64.9)	13 (35.1)	4.849	0.028*
No	153 (45.8)	181 (54.2)
Type of self-reported health problems
Musculoskeletal	7 (77.8)	2 (22.2)	9.076	0.106
Skin	5 (55.6)	4 (44.4)
Hypertension/diabetes	4 (100)	0
Respiratory	2 (40.0)	3 (60.0)
Others	6 (60.0)	4 (60.0)
No comorbidities	153 (45.8)	181 (54.2)

‘*Chi-square test used for analysis and P<0.05 was considered statistically significant

DISCUSSION

The present study showed that the prevalence of current tobacco and alcohol use is high among construction workers. Higher current tobacco consumption is associated with higher age group, married, lower education status, unskilled occupation, contractual workers, migrants from other states, more duration of work in construction field, and the presence of self-reported health problems (P < 0.05). Current alcohol consumption is associated with more duration of work in construction field and the presence of self-reported health problems (P < 0.05). The common self-reported health problems include musculoskeletal, skin and respiratory disorders, hypertension, and diabetes mellitus.

Majority of the workers belonged to 18–30 years of age group. Similar age distribution with more younger population was observed in other studies.[68910111213] More than three-fourth of them were migrants from outside states such as northern and northeast regions of India. Our findings were similar to the studies conducted in different parts of India where most of the construction workers were from eastern and northern parts of India.[89101314]

Other studies also reported high tobacco use. The findings regarding the prevalence of tobacco use in our study were similar to a study done in Kolar district, Karnataka (60.1%);[6] in Kozhikode district of Kerala (60.2%);[12] in Vidhyavihar (West), Mumbai (63.8%);[10] and another study from Mumbai (50.48%).[14]

Among smokers, the majority (60.9%) used bidi followed by cigarette (27.1%) and 12% used both. Similarly, a study in Kolkata found that 53% of the construction workers were smokers and they used mainly bidi. This might be due to the easy availability and comparatively less cost of bidies.[9] Among smokeless tobacco users, majority (83.4%) used khaini (plane tobacco leaves mixed with lime). A study carried out in Ahmedabad found that among tobacco users, 71.67% of construction workers used smokeless tobacco. This might be due to the fact that they were from northern and eastern parts of India where khaini is most commonly used.[15]

The prevalence of current alcohol use was 47.7%, which is higher than the study conducted in Kolar district, Karnataka (32.2%).[6] This was lower than present study may be because of the difference in study setting and methodology adopted. Another study in Kolkata showed that the prevalence of alcohol use was 37% which was also lower than our study due to the inclusion of women in this study and lesser sample size.[9] Another study in Kannur district, Kerala, showed that the prevalence of alcohol consumption was reported as 56.6% which was more than our study.[11] This may be due to migrant factory workers involved in this study.

The mean (SD) age of initiation of tobacco was comparatively lesser (20 years) than alcohol initiation (21.2 years) in the present study. A study conducted in Karnataka among construction workers also found initiation of smoking to be around 20 years.[8] However, another study found that age at initiation of nonsmoked tobacco users in factory workers was 25 years.[10] This might be due to the difference in the type of population and study setting. Studies in different groups in India found that the average age of alcohol initiation was in the range of 21–25 years.[161718] Peer pressure was found to be the main reason in this study for initiation of tobacco and alcohol use followed by stress and social cause, respectively. A similar finding was observed in a study conducted in Mysore, Karnataka.[8]

The proportion of tobacco users was highest in the age group of 46–60 years. Similar results were found in a study conducted in Karnataka that showed more tobacco use among above 40 years of age.[8] Similarly, married workers were more tobacco users among construction workers.[8] Construction workers with no formal education consumed more tobacco similar to another study.[10]

Ahmedabad study found that regular tobacco chewing was higher among nonmigrants than migrants in contrast to this study, but regular smoking was higher in case of migrant workers than nonmigrants.[15] Tobacco intake increases with increase in duration of work in construction field. This might be due to work stress, home sickness, and peer pressure. Karnataka study showed that people who were migrants for more than 20 years had a significantly higher proportion of smokers.[6] Construction workers start substance use early in their life during construction work period, and prevention measures early in their carrier may be adopted to prevent substance use. Hyderabad study showed that proportionately smokers had more morbidity similar to this study.[19] Since tobacco use is associated with comparatively more self-reported morbidities like musculoskeletal, skin, and respiratory disorders; hypertension; diabetes mellitus; and other morbidities, lifestyle changes for prevention of tobacco use may help in reduction of these morbidities in this target group.

The proportion of alcohol users increased with age. Similar results were found in Mumbai study which showed a higher use of alcohol in the age group of 40 years and above.[10] The proportion of alcohol consumption was more in participants from Puducherry and Tamil Nadu. It is almost similar to the National Family Health Survey-4 report of Tamil Nadu (47.7%) and Puducherry (45.2%) which is higher than national prevalence (29.2%) in men.[5]

About 7.5% of tobacco users and 3.9% of alcohol users were under high risk for health problems. A similar finding was found in a study conducted in Brazil. In this study, 5.7% of tobacco users were in the high risk and 6.9% of alcohol users were in the high risk of health problem.[20]

The tobacco and alcohol consumption is self-reported, and the possibility of social desirability bias and underreporting cannot be ruled out. Similarly, self-reported health problem was assessed based on previous diagnosis as mentioned by respondent, and there may be recall bias. The study was done in one construction site of Puducherry and because of difference in socio-demographic characteristics of working population in other construction sites, decision on generalizability to be made with caution. In spite of these limitations, this study gives valuable information on the magnitude of tobacco and alcohol use and its associated factors in construction workers which can be used for taking appropriate intervention measures to reduce its use.

CONCLUSIONS

Prevalence of current tobacco and alcohol use is high and health risk is also high in construction workers. More than one-third were using both tobacco and alcohol. Among current tobacco users, smokeless tobacco was comparatively more common than smoke form. Higher current tobacco consumption is associated with higher age group, married, lower education status, unskilled occupation, contractual workers, migrants from other states, more duration of work in construction field, and the presence of self-reported health problems. Current alcohol consumption is associated with more duration of work in the construction field and the presence of self-reported health problems. There is a need for instituting early prevention measures within the 1st year of induction into the profession for prevention of initiation of tobacco and alcohol use among construction workers. Periodic screening of the construction workers to identify the high-risk behavior of substance abuse and its reduction also should be emphasized. Services ranging from counseling to de-addiction therapies and affordable supply of pharmacological agents for those who need may be recommended.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.