Nicotine prevalence among youth of rural Jaipur, Rajasthan

ABSTRACT

Background:

Children are more sensitive to tobacco advertisements than adults. The World Health Organization (WHO) reported that tobacco use has doubled in the past four decades particularly among the youth. Smoking among teenagers is an issue that affects countries worldwide.

Objective:

This study identified the prevalence of tobacco consumption among youth of rural Jaipur. We also studied, their age of initiation of tobacco and their correlation with the income and occupation of parents.

Method:

Community based cross-sectional type of study was conducted on youth of 15-24 years of age in 30 clusters in the Vatika, Jaipur. Cluster sampling technique was adopted. A semi-structured pretested and predesigned questionnaire was used for data collection. The inter-personal communication technique was used maintaining full confidentiality. All the results were transferred onto Microsoft excel sheet and evaluated statistically.

Results:

Out of 420 youths, 79.0% youths consumes nicotine in any form. More male subjects (90.9%) consume nicotine than females (62.8%) highly significantly. 33.1% youths started nicotine consumption <12 years. Youths from more income family(63.6%), illiterate father (76.2%), illiterate mother (74.4%), father having farming as occupation (67.2%), consumes more nicotine. more (88.6%) of youths consume nicotine with their friends. 58.1% parents oppose their children.

Conclusion:

The prevalence of nicotine intake was higher in boys than girls and majority of them consumes nicotine in any form gutka or beedi-cigarette. The reasons for such high dependence of nicotine according to the youth were lack of knowledge of the ill effects of nicotine intake and peer pressure. However, majority of the youth did not want to quit nicotine consumption.

Introduction

Tobacco epidemic is one of the biggest public threats the world has ever faced, killing more than 7 billion people a year.[1] India is the second-largest consumer and third-largest producer of nicotine.[1]

Nicotine use, both in the form of smoke or smokeless, is a silent hazard and is one of the most commonly abused substances.[2] Nicotine use among the youth is alarmingly increasing in epidemic proportions across the globe.[2] Nearly 80% of people who have ever smoked daily smoked their first cigarette before they were 18 years old.[3] Smoking among teenagers is an issue that affects countries worldwide. Hence, it is necessary to stop the youth at an initial age.

It is easily available in various forms in India. Based on available evidence, it is estimated that 5% to 25% of Indian adolescents currently use or have ever used nicotine.[2] Even though smokeless tobacco is used less commonly, high rates of its use have been reported in India among adolescents aged 13 to 15 years.[2]

Children are more sensitive to tobacco advertisements than adults. The World Health Organization (WHO) reported that tobacco use has doubled in the past four decades, particularly among the youth.[4] Studies have also reported that adolescent youth who initiate tobacco use will continue using it lifelong, with very low quit rates.[4]

India’s youth is more susceptible to tobacco addiction, especially to smokeless tobacco. Youth from rural India, especially students, girls, and those from poor socioeconomic strata, prefer to use smokeless tobacco products.

Tobacco smoke is a risk factor for cardiovascular disease, asthma, pneumonia, lung cancer, and other cancers.[5] Smoking a pack of cigarettes a day quadruples the risk of developing oral cavity or oropharyngeal cancer, which kills 49% of its victims within 5 years of diagnosis.[4] Chewing tobacco increases the risk of cancers of the oral cavity (including cancer of the mouth, tongue, lip, and gums), throat, and esophagus, as well as leading to various oro-dental diseases.[6]

The present study provides new insights into the risk factors of chewing nicotine and smoking. Chewing nicotine and smoking have profound public health implications in terms of cardiovascular diseases, cancers, and neurological disorders that create a burden on the individual, family, society, and economy.[6] Early age of initiation of nicotine use drives its epidemic. Nicotine use among youth is associated with multi-factorial etiology. Thus, our current analysis has progressed with the objective of identifying the prevalence and exploring the association between various sociodemographic factors and nicotine usage among youths of rural Jaipur.

Material and Methodology

Community-based cross-sectional type of study was conducted on youth of 15-24 years of age in 30 clusters in the Vatika, the rural field practice area of Mahatma Gandhi Medical College and Hospital, Jaipur (10 km. from Mahatma Gandhi Medical College and Hospital).

A cluster sampling technique was adopted for the selection of youth of 15-24 years of age. While selecting the sample, all Mohallas in the rural field practice area of Mahatma Gandhi Medical College and Hospital, Jaipur, were listed. A list of all Mohallas (13) with a population of 17,523 was procured. A cluster interval (584) was obtained by dividing the total population by 30 (number of clusters). After reaching the center of the cluster, the investigator-generated a random number less than the cluster interval (x) with the help of a currency note. The cluster was represented by this number and was picked up as the first cluster, and subsequent clusters were selected by adding the cluster interval of 584. Thus, 30 clusters were selected on the basis of systematic random sampling from the probability of the cluster selection based on the population size of the cluster. In each cluster, every alternate household was studied in a sequence until a total of 14 youths of 15-24 years of age were covered. Likewise, 420 youths 15-24 years of age were selected from 30 clusters in the 13 Mohallas of the rural field practice area of Mahatma Gandhi Medical College and Hospital, Jaipur.

The purpose and methods of the study were explained to the selected youths. Appropriate written consent was taken before starting the interview (in the case of a minor, consent was taken from the mother). Pre-tested and pre-designed questionnaire was used. A semi-structured questionnaire was developed, and a pilot study was carried out to draw the necessary questionnaire, which was tested and retested for necessary modifications before proceeding to final data collection. The interpersonal communication technique was used to derive unbiased information and maintain full confidentiality. All the results were transferred onto Microsoft Excel sheet and evaluated statistically using appropriate statistical tests.

Results

Our study found that youth aged 15-18 years were 14.8%, 19-21 were 18.6%, and 22-24 were 67.6%. Among youths, males comprised 60.5%, and females comprised 39.5%. It was found that 40.9% were Hindus, and the rest, 59.1%, were others (Muslims, Sikhs, and Christians). The income per capita of the family ≥5000 Rupees was 60.0%, while 40.0% had an income of less than 5000 Rupees. 20% of the youth had working mothers, while mothers of 80% of the youth were homemakers.

Table 1 shows that out of 420 youths, 79.0% consumed nicotine in any form, while 21.0% did not consume nicotine. The association of nicotine intake among rural boys and girls (youth) is highly significant. More male subjects (90.9%) consume nicotine than females (62.8%). The association of nicotine intake with rural boys and girls was found to be highly significant. Table 2 shows the age at which the youth started intake of nicotine. 33.1% of youths started nicotine consumption below 12 years. 47.0% of youths started smoking during 12-15 years, and 19.9% of youth started after 15 years. The association of nicotine intake with the age of initiation was found to be highly significant.

Table 1.

Respondents who intake nicotine

	Male	Female	Total
Nicotine intake
Yes	231 (90.9)	101 (60.8)	332 (79.0)
No	23 (9.1)	65 (39.2)	88 (21.0)
Total	254 (60.5)	166 (39.5)	420 (100)

χ²-54.9221; df- 1; P<0.00001 (HS), Percentages in paraesthesis

Table 2.

Nicotine intake initiation among the youths

	Male	Female	Total
Age of initiation
<12	67 (29.0)	43 (42.6)	110 (33.1)
12-15	129 (55.8)	27 (26.7)	156 (47.0)
>15	35 (15.2)	31 (30.7)	66 (19.9)
Total	231 (100)	101 (100)	332 (100)

χ²-25.1188; df- 2; P<0.00001 (HS)

Table 3 shows that more respondents (63.6%) from families with more family income (i.e., >5000 per capita income) consume nicotine (63.6%) than families with less income (36.4%). Youths of illiterate fathers (76.2%) intake more than literate fathers (23.8%). Youths of illiterate mother (74.4%) intake more than literate mother (25.6%). Youths of fathers having farming as an occupation (67.2%) consume nicotine more than fathers with occupations other than agriculture. The association of literacy of mother and father with intake of nicotine among youth was highly significant. The occupation of a father with nicotine intake was highly significant. 23.8% of youths have working mothers, while 76.2% have homemaker mothers. The association of the mother’s occupation with nicotine intake was found to be significant.

Table 3.

Relation of Nicotine Prevalence by income of family, occupation of mother and Intake habits of respondents

	Nicotine intake		Total	Odd’s ratio; 95% CI	P
	Yes	No
Per capita Income of family
≤5000Rs.	121 (36.4)	47 (53.4)	168 (40.0)	OR- 0.5003; 0.3112 to 0.8042	0.0042
>5000Rs.	211 (63.6)	41 (46.6)	252 (60.0)
Education of father
Illiterate	253 (76.2)	81 (92.0)	334 (79.5)	OR- 0.2768; 0.1228 to 0.6236	0.0019
Literate	79 (23.8)	7 (8.0)	86 (20.5)
Education of mother
Illiterate	247 (74.4)	43 (48.9)	290 (69.0)	OR- 3.0410; 1.8719 to 4.9404	P<0.0001
Literate	85 (25.6)	45 (51.1)	130 (31.0)
Occupation of father
Agriculture	223 (67.2)	40 (45.5)	263 (62.6)	OR- 2.4550; 1.5221 to 3.9599	0.0002
Non-agriculture	109 (32.8)	48 (54.5)	157 (37.4)
Occupation of mother
Working	79 (23.8)	5 (5.7)	84 (20.0)	OR- 5.1834; 2.0304 to 13.2328	0.0006
House-maker	253 (76.2)	83 (94.3)	336 (80.0)
Total	332 (79.0)	88 (21.0)	420 (100)

Percentages in parenthesis

Table 4 shows more (88.6%) of youths consume nicotine with their friends. This was more in females (92.1%) than males (87.0%). Male youths (80.1%) were more influenced by the intake of their family member than female youths (28.7%). 58.1% of parents oppose their children i.e., more in females (89.1%) than males (44.6%), and this was highly significant. 83.7% of youths perceive cigarette smoking as harmful, which is more in females (87.1%) than males (82.3%). Only 33.1% of youths think of leaving it. Out of all females, 88.1%, and out of all boys, only 9.1% want to quit smoking. This association was highly significant.

Table 4.

Relation of Nicotine Prevalence with any family member, friends, or parental opposition

	Male	Female	Total	Odd’s ratio; 95% CI	P
Intake with friends
Yes	201 (87.0)	93 (92.1)	294 (88.6)	0.5763 0.2544 to 1.3056	0.1866
No	30 (13.0)	8 (7.9)	38 (11.4)
Family members’ intake of nicotine
Yes	185 (80.1)	29 (28.7)	214 (64.5)	9.9850 5.8268 to 17.1106	<0.0001
No	46 (19.9)	72 (71.3)	118 (35.5)
Parental opposition
Yes	103 (44.6)	90 (89.1)	193 (58.1)	0.0984 0.0499 to 0.1937	<0.0001
No	128 (55.4)	11 (10.9)	139 (41.9)
Perception of smoking as harmful
Yes	190 (82.3)	88 (87.1)	278 (83.7)	0.6846 0.3492 to 1.3420	0.2699
No	41 (17.7)	13 (12.9)	54 (16.3)
Have you thought of leaving?
Yes	21 (9.1)	89 (88.1)	110 (33.1)	0.0135 0.0064 to 0.0286	<0.0001
No	210 (90.9)	12 (11.9)	222 (66.9)
Total	231 (100.00)	101 (100.00)	332 (100.00)

Percentages in paraesthesis

Discussion

The present study entitled “Nicotine prevalence among youth tobacco users in rural Jaipur, Rajasthan” was carried out in the Department of Community Medicine, Mahatma Gandhi Medical College, Jaipur. In this cross-sectional study, the selection of youth aged 15-24 years (n = 420) was carried out in 30 clusters in rural areas of Jaipur district. The data was collected regarding sociodemographic variables like age, gender, prevalence, occupation, and income of the family in relation to the intake of nicotine. These 420 interview study schedules were analyzed and discussed with the findings of other authors.

In our study, such a high rate of nicotine intake (79.0% of youths) is observed among the rural youths of Jaipur, Rajasthan. This is also seen in many other studies, indicating that the majority of the youth consume nicotine in any form. Nicotine is used in a wide variety in India. In the current scenario, cigarettes are most commonly used by youth, followed by bidis, and in smokeless form, its gutka is very common. Rachiotis G et al. 2008 found 48.2% and 47.6% prevalence with odds ratio of 2.64 and 1.5 resp.[7] Reddy U et al. conducted a study in which out of the 248 tobacco users, 68.5% of students were smokers.[8] While Grover S et al. found only 11.9% of youths using nicotine in any form.[2] The social acceptability of tobacco, particularly smokeless forms since ancient times, made it widely prevalent in rural areas.[2] However, the health of people living in rural areas is impacted more by tobacco use due to socioeconomic factors, culture, policies, and lack of proper health care.[2]

Gender also emerged as an important factor for it is used in our study, with male youths (90.9%) more likely to use any form of nicotine as compared with females (60.8%). Nicotine use, particularly smoking, is a male-dominated phenomenon among children and adolescents in India. This is also found in the study of Prasad LK et al.[9] Similar to our study, Grover S et al. and Bhattacharya S et al. also found more males (72.2% and 83.5%) consuming nicotine than females (27.8% and 57.7%), respectively.[2,1] The reasons might be the usual false perceptions that a smoking man: is “successful, intelligent and macho,” “risk-taking,” and has “strong masculinity,” and that chewing tobacco leads to ‘better athletic performance’ and “rule-breaking risks” in contrast to females who are perceived as culturally unacceptable in Indian societies if they smoke or chew tobacco.[6]

In our current study, nearly one-third of youths started nicotine consumption before 12 years, and nearly half started consuming it between 12-15 years. In a study conducted by Jaisoorya T et al., the mean age of onset of tobacco use was 14.0 ± 2.2 years.[10] Prasad LK stated that the average age at initiation of tobacco usage was 17, with 25.8% of females starting the habit before 15 years of age.[9] The majority of schoolchildren started to smoke between 15 and 18 years of age, according to a study conducted by Reddy UK et al.[8] Grover S et al. found the overall mean age of initiation of tobacco use was 17.8 years in Delhi.[2] From all the studies, we conclude that the majority of the youth start nicotine intake before the age of 18 years.

Family income and the mother’s occupation also play a significant role in the nicotine intake of youths. Youths with more earning parents (63.6%) have more usage of nicotine than youths of less earning parents (36.4%). Liang YC et al., Rachiotis G et al., and Siziya S et al. also found increased pocket money for adolescents who smoke.[3,7,11] As the association of nicotine intake with a mother’s occupation was highly significant, 76.2% of the youth who intake nicotine had working mothers, while 23.8% of the youth who intake nicotine had mothers as house makers.

Parents and peers can influence smoking in adolescents. In the current study, youths with smoker friends were about eight times more likely to be nicotine consumers than youths with non-nicotine consumer friends. In our study, respondents whose parents consumed nicotine in any form (64.5%) had higher intake as compared to their counterparts (35.5%). Having smoker parents and peers was positively associated with smoking initiation in adolescents. Liang Y C et al. also found that the parents of 65.7% of the current smokers were smokers themselves, and friends of 39.4% of the current smokers were also smokers.[3] It is similar to the study of Roble AK et al. on adolescents in Ethiopia.[5] Liang YC et al. found an OR of 1.65 as both parents were smokers and an OR of 36.27 as most friends smoke.[3]

In our study, only one-third of youths think of leaving nicotine consumption. Islam K et al. in West Bengal in 2014 stated 37.8 to 51.7% variation in the intention of quitting.[12] Liang Y C et al. observed that 58.3% of smokers feel quitting is hard.[3]

The study had a few limitations. The survey is cross-sectional in design and hence limits the establishment of temporal association and measurement of social patterning of nicotine use over time. Furthermore, a lack of adequate responses to questions pertaining to the type of smoking and smokeless forms used by youth limits its generalizability. Also, there could be inconsistencies in self-reported age of initiation of daily tobacco use. This is a potential limitation of self-reported data, and it affects its reliability.

Conclusion

Nicotine intake was widely prevalent in rural youths despite having knowledge of the ill effects of it. The prevalence of nicotine consumption was higher in boys than girls, and the majority of them consume nicotine in a smokeless form, gutka. The reasons for such high intake may be peer pressure, influenced by their parents, or more pocket money. They think products are appropriate and that smoking, especially among peers, is stylish, fashionable, and acceptable. However, the majority of the youth did not want to quit it. A strong and robust awareness program at the community level is therefore the need of the hour.

A total approach by the school health program must include teacher orientation and health education of children. Periodic screening of school children is essential since the majority of the youth started smoking in the age group of 12-15 years. In every school, seminars must be conducted to help the youth either stop or quit nicotine intake.

Lastly, we conclude that the natural instinct of the youth to try new things, follow their family members, and do things under peer pressure must be considered while counseling these children. So, prevention and intervention programs need to be implemented.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.