A Cross-sectional Study to Assess Factors that Determine Tobacco Habit Initialization and Cessation and Oral Cancer Awareness among General Population of Vikarabad District, Telangana.

AIMS: The aim of the study was to assess factors that determine tobacco habit initialization and cessation and oral cancer awareness among the general population of Vikarabad district, Telangana.
MATERIALS AND METHODS: The current study was a cross-sectional study conducted among the general population of the Vikarabad district. All tobacco users satisfying inclusion criteria of age 18-40 years and at least 1 year of tobacco usage were included in the study. Multistage random sampling was followed to select tobacco users and structured, pretested questionnaires were distributed. The populations mean age was 30 years with majority being rural residents and men contributing the majority of the study population.
RESULTS: The mean age at which a person begins to smoke was 20.4 ± 5.7 years among the general population. Peer influence (77%) was reported as one of the major reasons, and habit formation was found to be the major factor (55.6%) for continuing tobacco and also work stress (17%) and relaxation (17%). The primary reason for quitting was fear or awareness of the adverse effects of tobacco. Self-abstinence was reported as a predominant method that they followed to quit tobacco habit during the past year, while 16.3% reported that they did not give it a try. About 58.6% of participants were advised by a health-care provider to quit tobacco, respectively. A major proportion of tobacco users (71%) knew that tobacco causes oral cancer. Half of the study population is unaware of oral cancer's early symptoms, noncontagious progression, lifestyle modification, and early treatment have a good prognosis.
CONCLUSION: Findings of the study highlight the factors to be considered in framing effective antitobacco policies applicable to the rural population. Copyright:

INTRODUCTION

Modern civilization, industrialization, urbanization, changes in day-to-day life, population growth, and aging all have contributed to epidemiological changes in many diseases, including cancer, in India and other countries. In India, noncommunicable diseases were the leading cause of death in 2012, with an estimated burden of more than 1 million people diagnosed with cancer per year.[1] The National Programme for the Prevention of Cancer, Diabetes, Cardiovascular Disease, and Stroke, which has incorporated the earlier National Cancer Control Programme since2010, has made cancer a priority.[2]

Tobacco is classified as a category 1 carcinogen and is the leading cause of cancer, accompanied by alcohol intake, poor eating habits, insufficient physical activity, viral infections, and sexual activities.[34] Tobacco has historically been considered a corrupting addiction, and addiction signs occur after a certain period of time, which can be comparable to a time bomb explosion.[5]

Tobacco users are a high-risk group for noncommunicable diseases; generally, this offers an opportunity to address multiple noncommunicable diseases in the same setting. Primary prevention, in the form of education and therapy about smoking and alcohol abstinence services, is a crucial and potential prevention method for these high-risk groups.

All types of tobacco use were found to be highly affected by age, education, and geographic location. Tobacco use is affected by a lack of awareness about particular tobacco risks.[6]

Each individual who refuses to heed tobacco warnings is driven by a complex web of motivation and addiction. Knowing the multiple factors influencing tobacco habit helps in formulating effective tobacco cessation curricula which influence health-care students' future clinical practice behavior.[78] Tobacco being the prime factor in the development of oral cancer apart from habit-related information exploring awareness among tobacco users regarding oral cancer will be of no use. Literature about the awareness regarding oral cancer in the Indian population is very less.[9]

Keeping in mind the above reasons and need, our study was directed to measure the factors influencing tobacco habit characteristics, which is the root cause of high tobacco intake. This study aimed to assess factors that determine tobacco habit initialization and cessation and oral cancer awareness among the general population of Vikarabad district, Telangana.

MATERIALS AND METHODS

Study design

A cross-sectional epidemiological survey was conducted to assess factors that determine tobacco habit initialization and cessation and oral cancer awareness among the general population of Vikarabad district, Telangana. The district is spread over an area of 3386.00 km2. As per the 2011 census, the population was 3,927,140, and population density was 274 persons/km2.

Source of data and study population

The study population comprised ever tobacco users[10] among the general population of Vikarabad district, Telangana. Ever tobacco users refer to subjects who in their life have ever used tobacco of any kind. Inclusion criteria: (1) subjects aged 18–40 years, (2) individuals who disclosed their tobacco habit; (3) subjects having a history of tobacco consumption for a period of at least 12 months in a lifetime and the unwilling, mentally challenged, and subjects previously diagnosed with oral cancer were excluded.

Sample size determination and sampling procedure

A pilot study was performed on fifty tobacco users were randomly selected from two villages to assess the feasibility of the survey and to notice any difficulties encountered during data collection through questionnaire, as well as to ensure the questionnaire's level of validity and reliability (Cronbach's = 0.89), and the data from the pilot study were not included in the main survey. The sample size for the study was obtained from the formula:

nh = (Z2) (r) (1 − r) (f) (k)/(p) (n) (e2)

Statistic for 95% confidence interval (CI), Z = 1.96, expected proportion of important initiating or cessation factor, r = 0.10, design effect, f = 2, nonresponse, k = 1.1, total population for whom the parameter is applicable, P = 0.75, family size, n = 5, relative error, e = 0.15, sample size = (1.96) 2 (0.1) (0.9) (2) (1.1)/(0.75) (5) (0.015) 2 = 780 which was rounded up to 800.

A multistage random sampling technique was used. Using the lottery system, four mandals were randomly chosen from each revenue division, and four villages were chosen from each mandal. Thirty-two villages were chosen, with a total sample of 800 subjects spread evenly around the 32 villages, i.e. 25 subjects per village.

Before the study began, the Institutional Review Board of Sri Sai College of Dental Surgery, Vikarabad granted ethical approval (ref no. 557/2/COMD/SSCDS/IRB-E/2015). Following their guidance, relevant recommendations were integrated into the current study. Before the study, all participants gave their informed consent.

Data collection

Scheduling

Data collection was systematically scheduled to spread over 4 months, i.e. from May 2017 to August 2017. In spite of having a scheduled plan, few adjustments and changes had to be made while working it out practically.

Questionnaire

A self-designed structured questionnaire with questions customized to fulfill study objectives was used as a study instrument. The questionnaire included self-composed questions and questions adapted from previous literature, modified, and adapted contextually. The questionnaire was prepared including the sociodemographic details, tobacco habit characteristics, and oral cancer awareness.

The questionnaire constructed was then sent to an expert committee for checking its content and face validity. Later necessary corrections and modifications were done and were made ready to use in the research.

Participants were assured of anonymity as no information which reveals the identity of the participant was recorded in the questionnaire. Participation was not forced. Questionnaires were distributed to literates, whereas questions were read out loud for illiterates and literate subjects who requested for the same to record their answers. Forms with missing details were excluded from the analysis.

Statistical analysis

The data collected were compiled and double checked for accuracy. The analysis was carried out with the aid of the Statistical Package for the Social Sciences (SPSS 20.0 Version, Armonk, New York, USA). To record means and standard deviations for continuous variables and frequency distribution for categorical variables, quantitative descriptive analysis was performed using univariate statistics. The frequency of categorical variables was compared using Chi-square analysis. If P = 0.05 with a 95% confidence interval, the likelihood of occurrence by chance is significant. Microsoft Word was used to construct the tables and graphs.

RESULTS

The demographic features of the sample population are shown in Table 1. The mean age of the study population was 32.18 ± 6.42 years. The majority of them, i.e. 97.2% were males and were farmers, i.e. 53.8%. There was an approximately equal number of literates and illiterates.

Table 1

Distribution of study population based on their demographic variables

Factors	Categories	Respondents, n (%)
Age (years)	<30	364 (45.5)
	>30	436 (54.5)
Gender	Male	778 (97.2)
	Female	22 (2.8)
Occupation	Unemployed	70 (8.8)
	Unskilled worker	158 (19.8)
	Semi-skilled	67 (8.4)
	Skilled	46 (5.8)
	Farmer	430 (53.8)
	Semi profession	18 (2.3)
	Profession	11 (1.4)
Education	Literate	415 (51.9)
	Illiterate	385 (48.1)
BG Prasad socioeconomic classes based on per capita income	Class I	65 (8.1)
	Class II	116 (14.5)
	Class III	134 (16.8)
	Class IV	316 (39.5)
	Class V	169 (21.1)
Residence	Rural	720 (90)
	Urban	80 (10)

The percentage distribution of the study population based on tobacco habit characteristics is shown in Table 2. The majority of study participants, i.e. 60.1% were consuming tobacco daily.

Table 2

Distribution of study population based on tobacco habit characteristics

Question	Option	Respondents, n (%)
How often do you use tobacco product?	Daily	481 (60.1)
	Less than daily	132 (16.5)
	Not at all	187 (23.4)
Type of tobacco product you have consumed or still consuming?	Smoke	512 (64.0)
	Smokeless	257 (32.1)
	Combined forms	31 (3.9)
Does anyone in your family consume tobacco?	Yes	572 (71.5)
	No	228 (28.5)

Among them, 64.0% and 32.1% were still consuming smoke form and smokeless form of the tobacco product, respectively. The rest 3.9% consumed or were still consuming both forms of tobacco product. Seventy-one percent of the study population had a family member who consumed tobacco.

Table 3 shows the percentage distribution of the study population depending on the factors that led to the development of a tobacco habit. Around 41% said they started smoking for the first time when they were between the ages of 19 and 25. The mean age of initiation was found to be 20.4 ± 5.7 years among current study participants.

Table 3

Distribution of study population based on tobacco habit initiation factor

Question	Options	n (%)
How old were you when you started using tobacco product for the first time? (years)	≤15	200 (25.0)
	15-18	139 (17.4)
	19-25	328 (41.0)
	Above 25	133 (16.6)
How did you get your first tobacco product?	I bought it myself	110 (13.8)
	Friends offered me	590 (73.8)
	My family members offered me	91 (11.4)
	Others	9 (1.1)
What was the main reason due to which you have started consuming tobacco?	Peer influence	616 (77.0)
	Curiosity	31 (3.9)
	Family influence	76 (9.5)
	Stress	30 (3.8)
	Fantasy and fashion	1 (0.1)
	Other reasons	46 (5.8)

Around 73.8% of the study participants decided that their friends were the ones who gave them their first tobacco product, and 77% said peer pressure was the key reason they started smoking.

Table 4 shows the percentage distribution of the study population based on the variables that influence tobacco habit continuity. More than half of the study participants (55.6%) said that habit forming was the most important factor in continuing their tobacco habit, and 96.9% reported that the availability and accessibility of tobacco products increased their chances of tobacco consumption.

Table 4

Distribution of study population based on tobacco habit continuation factors

Question	Option	Respondents, n (%)
What are the factors that are influencing you to continue tobacco habit?	Work stress	143 (17.9)
	Habit	445 (55.6)
	Delay hunger	3 (0.4)
	Relaxation/mood enhancement	137 (17.1)
	Others	72 (9.0)
Does accessibility and availability to product increase your chance of tobacco consumption?	Yes	775 (96.9)
	No	25 (3.1)

The distribution of the study population based on oral cancer awareness levels is shown in Table 5. About three-quarters of the study population stated that they had heard of oral cancer. Tobacco causes oral cancer, according to 71.1% of the study population. Nearly 57.3% of the study participants said they did not know oral cancer could be avoided, while 2% of them declined it. It was described as a noncontagious disease by about 13% of the study population. More than half of the participants in the study had no idea that nonhealing ulcers in the mouth could be a sign of oral cancer.

Table 5

Distribution of study population based on oral cancer awareness levels

Question	Option	n (%)
Have you ever heard of oral cancer?	Yes	572 (71.5)
	No	228 (28.5)
	Don’t know	0
Are you aware that tobacco causes oral cancer?	Yes	569 (71.1)
	No	231 (28.9)
Do you think that oral cancer is preventable?	Yes	326 (40.8)
	No	16 (2.0)
	Don’t know	458 (57.3)
Do you think that oral cancer is contagious?	Yes	105 (13.1)
	No	104 (13.0)
	Don’t know	591 (73.9)
Nonhealing ulcer in mouth is indicative of oral cancer?	Yes	375 (46.9)
	No	4 (0.5)
	Don’t know	421 (52.6)
Is treatment of oral cancer possible?	Yes	403 (50.4)
	Don’t know	397 (49.6)
Diagnosis of oral cancer at early stages will have good prognosis	Yes	450 (56.3)
	Don’t know	350 (43.8)
Modification of life style habits reduces the risk of developing oral cancer?	Yes	448 (56.0)
	Don’t know	352 (44.0)

Around 50.4% of the study population agreed that oral cancer should be treated, and about 56.3% agreed that early detection of oral cancer would result in a good prognosis, while 43.8% said they did not know.

The association between initiation factors, cessation factors, and demographic variables is shown in Table 6. With P < 0.001, there was a statistically significant association between initiation and cessation factors, as well as age group, occupation, education, and socioeconomic status of participants. There was no statistically significant association between gender and initiation factors (P = 0.09), but there was a statistically significant association between gender and cessation factors (P = 0.004). With P < 0.001 and P = 0.05, respectively, there was a statistically significant association between initiation, cessation factors, and residence.

Table 6

Association between tobacco habit initiation, cessation and demographic variables

Factors	Categories	P
		Initiation factors	Cessation factors
Age (years)	<30	0.001*	0.001*
	>30
Gender	Male	0.09	0.004*
	Female
Occupation	Unemployed	0.001*,#	0.001*,#
	Unskilled worker
	Semi-skilled
	Skilled
	Farmer
	Semi profession
	Profession
Education	Literate	0.001*	0.001*
	Illiterate
BG Prasad socioeconomic classes based on per capita income	Class I	0.001*,#	0.001*,#
	Class II
	Class III
	Class IV
	Class V
Residence	Rural	0.001*	0.06
	Urban

#Fishers exact test, *P<0.05 Statistically significant

DISCUSSION

Tobacco use is one of the most dangerous activities that people engage all over the world. Tobacco use and second-hand smoke are responsible for approximately 6 million deaths worldwide per year.[11] Although literature establishes nicotine to be the reason for tobacco addiction, other factors responsible for initiation and cessation of tobacco habit have not been explained comprehensively. The lack of awareness about the real risks of tobacco has a huge effect on its use.[6] The factors associated with initiating and quitting tobacco have been investigated. Peer pressure and delinquent behavior were initiating factors.[121314] Health concerns and financial stress were the main motivators for tobacco cessation.[151617] With increasing demand among tobacco users to quit tobacco.[18] To establish effective approaches to minimize tobacco-related morbidity and mortality, it is important to first consider the all-encompassing roles of multiple factors responsible for initiation and the role of barriers in cessation.[19]

Tobacco being the prime factor in the development of oral cancer apart from habit-related information exploring awareness among tobacco users regarding oral cancer will be invaluable. Literature about the awareness regarding oral cancer in the Indian population is scarce.[9] As a result, this cross-sectional study was conducted to determine the factors that contribute to the initiation and continuation of a tobacco habit, as well as levels of oral cancer awareness among the general population.

Population-based surveys are recommended in rural areas where approximately 72% of the population reside with high illiteracy rates, low socioeconomic status, and poor access to health education hence knowledge about the ill effects of tobacco is much needed.[20] The study area of the current study was predominantly rural, with 90% of participants residing in rural areas.

Men represented 97.2%, whereas women represented 2.8% of the study population. The low proportion of female tobacco users was reported in studies done by Subba et al. and Chezhian et al., which is in line with current study findings.[2122] It is possible that the low proportion of female smokers is due to sociocultural stereotypes, the age group of study participants, and gender-related stigma.

The literacy rate of the Telangana state as per the 2011 census is 66.54%.[23] There were approximately an equal number of literates 51.9% and illiterates 48.1% among the participants of the current study. The proportion of illiterates was higher than state literacy might be due to the rural setting of the study.

The mean age of initiation among current study participants was found to be 20.4 years (standard deviation [SD] = 5.7). Denny et al. and Chezhian et al. reported analogous mean age of around 20 years (SD = 4) at which most of the participants started using tobacco.[1922] An utmost percentage of the current study population (77%) stated that peer influence was the main reason due to which they have started consuming tobacco. These findings are in concordance with findings of Naing et al.'s study where peer influence was found to be the major reason (75%) of tobacco use initiation among adolescents.[24] The current study findings are in contrast with Denny et al.'s study findings where relief from the tension (30%), followed by peer influence (18%) were reasons for initiation.[19]

Farmers perceived peer influence to be the main reason probably due to habit being considered normal in their peer network. The current study findings report that there exists a statistically significant association between age, residence, socioeconomic status, occupation, and reasons being perceived responsible for habit initiation among users. It was found that gender had no significant association with reasons for initiation reported among current study participants. This was in concordance with study reports by Escoedo LG et al. on American population where sociodemographic variables influence habit initiation[25] Duc et al. studies on tobacco initiation in Vietnamese population report similar results. Despite the fact that tobacco is now commonly known as a cancer risk factor, there are still pockets of society that are unaware of the correlation between tobacco and disease who were approximately 29% in the current study. This is in line with Aguiar et al. study where 20% have stated the same.[16] This signifies much more targeted efforts to reach the unreached sections of the community.

Limitations in this study are inherent due to its cross-sectional nature where one cannot establish a temporal association between predictors and dependent factors.

Besides limitations, the current study population was sampled from the general population which better represents the community and results can be extrapolated. Understanding the predictors of oral cancer awareness is crucial for potential educational initiatives directed at the high-risk community for oral cancer, especially tobacco users. The combined efforts of the public and private sectors, with the help of health professionals, could help raise awareness of the hazards of smoking and encourage people to participate in smoking prevention programs. Tobacco cessation strategies should take into account the multifaceted nature of tobacco initiation and cessation, especially in rural areas.

CONCLUSION

Peer influence (77%) was the major initiating factor among tobacco users. About 41% of participants stated that they started using tobacco when they were in 19–25 years of age. Mean age of initiation was noticed to be 20.4 ± 5.7 years. About 72% of tobacco users are aware that tobacco causes oral cancer. About half of tobacco users are aware that modification of lifestyle habits reduces the risk of developing oral cancer.

Recommendations

Tobacco ban should be encouraged like narcotic drugs and should be comprehensive making it inaccessible to all. As the ban may affect the laborers who are working in the tobacco industry, they need to be provided any other line of work

Encouraging clinic-based tobacco cessation centers in rural areas is essential

Other avenues to investigate include different forms of stress management among tobacco consumers, which could aid in prevention and cessation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.