Assessment of nicotine dependence among tobacco users in a rural area of Salem, Tamilnadu: Community based cross sectional study

ABSTRACT

Background:

India is the 2^nd largest consumer of tobacco worldwide. Tobacco use for longer duration leads to nicotine dependance and also increases the chances of dependance to other substances Morbidity and mortality rates are increasing due to tobacco use.

Objectives:

1. To estimate the prevalence of physical and psychological nicotine dependance among tobacco users in rural area. 2. To determine the factors associated with of physical and psychological nicotine dependance among tobacco users in rural area.

Materials and Methods:

It is a community-based analytical cross-sectional study conducted among 405 tobacco users (>18 years) in the field area of a Medical College in Tamil Nadu. A pre-tested structured questionnaire was used to collect data including Fagerstrom physical nicotine dependance scale and TAPDS psychological dependance scale. The data was entered in MS Excel and analysis was done using SPSS software (version 22).

Results:

Mean age was 36 ± 11.2 Years and 284 (70.1%) were males. Nearly 270 (66.7%) use smoked form of tobacco, and 88 (21.7%) were using tobacco for ≥10 Years About 179 (44.1%) and 120 (29.6%) had high and moderate physical dependence respectively. Also, 127 (31.3%) had mild psychological dependence. In binary logistic regression analysis, high physical nicotine dependance was significantly associated with male, age of initiation of tobacco use <30 Years, and ≥10 Years of tobacco use. Psychological nicotine dependance was associated with male gender and ≥10 Years of tobacco use.

Conclusion:

Even though many legislative measures and acts were passed by the government nicotine dependance prevalence was high in this area. Lifestyle modification plays a key role in nicotine dependance, and change in the harmful lifestyle habits must be adopted. The target population for this strategy will be adolescents and early adults.

Introduction

Globally, tobacco consumption is one among the prime causes of preventable death in human race.[1] According to a global estimate of tobacco usage made in the year 2014, around 300 million people all around the world are using smokeless form of tobacco and nearly 5.8 trillion cigarettes were smoked. Among the overall cigarettes smoked, major share was from the South East Asian regions.[2] Nearly 150 million of the younger population are using tobacco in any form and a vast, majority among them stated to use them in the early adolescence.[3]

According to the Global Adult Tobacco Survey (GATS 2:2016-17) report released in India, almost 42.4% of the men and 14.2% of the women are using either smoked or smokeless tobacco. About 55.4% and 49.6% among them were willing to quit smoking and smokeless tobacco respectively.[4] Tobacco usage is largely to blame for the loss of healthy years owing to disability and early mortality worldwide. Smoking causes over 90% of deaths and diseases linked to tobacco use, which is exceedingly dangerous for human health. In India, the proportion of Disability Adjusted Life Years (DALY) linked to tobacco use is 5.4%, while the global range is 0.6% to 19%.[2]

Nicotine dependance in an individual is due to the interplay of many factors like genetic, psychological factors and lifestyle.[5] Nicotine being and psychoactive and neuroadaptive substance produces dependance and increases the rate of consumption further.[6] Nicotine dependance is been included in the international classification of Diseases (ICD 10) given by the World Health Organization.[7] Nicotine dependance prevalence varied from 12.4% to 83% globally and comparison of nicotine dependance across 13 nations showed that United states and Sweden had the highest nicotine dependance score and the scores were the lowest for Norway and Germany.[8]

It is essential to recognize nicotine dependance at the earliest and give proper treatment in order to overcome the health issues associated with it and to make the quitting policy successful.[9] The Indian government has launched many acts and legislative measures like COTPA (Cigarette and Other Tobacco Products) act, MPOWER policy, M cessation program to limit the usage of tobacco, to ban the advertisements for tobacco related products and to increase the level of awareness towards the harmful effects of tobacco usage.[10] In spite of these measures, the 2^nd largest consumer of tobacco is India, and the consumption rates keep on increasing.[11,12]

In India, very minimal studies have assessed both physical and psychological dependance for nicotine. In order to bridge this gap, the present study was carried out to estimate the prevalence and determinants of nicotine dependance in a rural area of Salem district Tamil Nadu.

Methodology

Study design

It is a community-based analytical cross-sectional study.

Study area

This study was conducted in Veerapandi which is the rural field practice area of the Rural Health and Training Centre (RHTC) attached to the tertiary care hospital in Salem district of Tamil Nadu.

Study population

Study population identified were tobacco users above 18 years residing in the study area permanently at the time of the study.

Sample size

Sample size was calculated based on a previous study conducted by Divinakumar KJ et al.[13] in Bangalore during 2018 with a prevalence of nicotine dependence as 35%. This was taken as the reference value for calculating sample size. The sample size was calculated using the formula N = Zά²pq/[L] 2. Accounting 15% for non-response, the final sample size was calculated as 405.

Sampling method

Systematic random sampling technique was used to identify the study subjects. Sampling Interval (N/n) was calculated as follows: [N = Total number of households in the study area = 1548, n = sample size = 405. N/n = 1648/405 = 4]. Thus every 4^th house was selected for identifying tobacco users above 18 years of age.

Inclusion criteria

Adults aged 18 years and above who were using tobacco in any form at least for the past 1 year residing in the study area and willing to participate were included.

Exclusion criteria

The exclusion criteria for the study were

1. Those who have quit tobacco.

2. Those in the process of detoxification like those using nicotine gums and patches.

3. Pregnant and lactating mothers.

4. Psychiatric patients and critically ill patients.

5. Persons with dependence to other substances like alcohol, opioids, and cannabis.

Study period

This study was done for the period of 12 months (November 2022 - October 2023)

Informed consent and ethical clearance

Informed consent and Institutional ethical committee approval (Ref no: VMKVMC and H/IEC/21/188) were obtained prior to conduction of the study.

Data collection

The data was collected using the pretested structured questionnaire by face to face interview by the investigator. Nicotine dependence was assessed using Fagerstrom test for nicotine dependence (FTND) and test to assess the psychological dependence on smoking (TAPDS) scales. Questionnaire consisted of Sociodemographic characteristics, pattern of tobacco use, nicotine dependence scales, knowledge regarding nicotine dependence, and morbidity profile. Interviews were performed in the local vernacular language (Tamil) of study participants. Each interview lasted about 30 to 40 minutes in a place convenient and comfortable to the participants.

Statistical analysis

Data entry was done in Microsoft Excel and data analysis was done in SPSS software version 22. Descriptive statistics like Percentage, Proportion, Mean, and Standard deviation were done. Univariate analysis to determine association between nicotine dependence and study variables was done using Chi-square with estimation of Odds ratio. Binary logistic regression was done to estimate Adjusted odds ratio. P value < 0.05 was considered as significant.

Operational definitions

1. Physical nicotine dependence[14]

   Physical dependence was assessed using FTND scale. The FTND is a short scale comprising of 6 items which quantify nicotine dependence. If the overall scores for severity of dependance:

   • 1-3: Minimal dependance.

   • 5–7: Moderate dependance.

   • 8–10: High dependance.

2. Psychological dependance[15]

   Psychological dependance was assessed using TAPDS scale and it consists of 8 items. If the overall score is

   • 8-13: Mild dependance.

   • 14-19: Moderate dependance.

   • 19-24: Severe dependance.

Results

Mean age of the study population was 36 ± 11.2 Years and majority of them were males accounting to 70.1%. Nearly 23.9% were illiterate and 31.4% had ≥ high school education. As per the socioeconomic status classification, only 18.9% belonged to upper socioeconomic class and 29.9% falls in upper lower class. Almost 77% were from nuclear family and majority 93.3% takes mixed diet in this study population [Table 1].

Table 1.

Sociodemographic characteristics of the study population (n – 405)

Variables	Frequency	Percentage (%)
Age (in Years)
18-44	129	31.8
45-59	188	46.5
≥60	88	21.7
Gender
Male	285	70.1
Female	120	29.9
Religion
Hindu	398	98.3
Muslim/Christian	7	1.7
Marital Status
Married	348	85.7
Unmarried	39	9.6
Separated/Divorced/Widow	18	4.7
Education
Illiterate	97	23.9
Primary School/Middle School	181	44.7
≥ High School	127	31.4
Occupation
Unemployed	36	8.9
Unskilled/Semi-Skilled	299	73.8
≥ Skilled	70	17.3
Socio-Economic Status
Upper Class	76	18.9
Upper Middle Class	100	24.6
Lower Middle Class	83	20.4
Upper Lower Class	85	29.9
Lower Class	61	15
Family Type
Nuclear	312	77
Joint Family/Three Generation Family	93	23
Diet
Mixed	378	93.3
Vegetarian	27	6.7

More than half, 66.7% of them use smoked form of tobacco and about 1/4^th started to use tobacco before the age of 20 years. Around 21.7% were using tobacco for ≥10 Years and nearly half of the study participants use tobacco for ≤5 times in a day. Nearly 2/3^rd were using tobacco either to relieve stress or for leisure. Around 48% have the habit of consuming tobacco in home and 61.6% of them quoted tobacco use among family members [Table 2].

Table 2.

Pattern of tobacco usage among the study population (n – 405)

Variables	Frequency	Percentage (%)
Type of tobacco usage
Smokeless	145	33.3
Smoked	270	66.7
Age of starting tobacco usage
<20 years	97	24.1
20-29 years	134	33,0
30-39 years	127	31.3
≥ 40 years	47	11.6
Duration of tobacco usage
≥15 years	88	21.7
10-14 years	80	19.9
6-9 years	117	28.8
≤5 years	120	29.6
Frequency of usage/day
≥15 times	35	8.6
10-14 times	52	12.9
6-9 times	117	28.9
≤ 5 times	201	49.6
Reason for tobacco usage
To relieve stress	302	74.6
Leisure
Peer influence	90	22.2
Use in family
No specific reason	13	3.2
Will you use tobacco in home
Yes	194	48
No	211	52
Tobacco usage among family members
Yes	250	61.6
No	155	38.4
Ever tried quitting tobacco use
Yes	332	81.8
No	73	18.2

Among the tobacco users, 44.1% and 29.6% had high and moderate physical nicotine dependence respectively. About 31.3% and 13% had mild and high psychological nicotine dependence. Whereas, about 27.2% of them had no psychological dependence to tobacco [Figure 1].

Figure 1.

Prevalence of physical and psychological nicotine dependance among the study population (N – 405)

High physical nicotine dependence was significantly associated with Male gender (P value - <0.0001, OR – 3.10), ≤ high school education (P value - <0.0001, OR – 3.87), Nuclear family (P value - <0.0001, OR – 4.32), age of initiation of tobacco use < 30 Years (P value - <0.0001, OR – 6.94), ≥ 10 Years of tobacco use (P value - <0.0001, OR – 4.01) [Table 3].

Table 3.

Association between high physical nicotine dependance and selected factors among the study population (n – 405)

Variable	Total frequency	High physical dependance to nicotine
		Yes (179)	No (226)	P	Odds ratio (95% CI)
Age
≤45 Years	169	72	97	0.584	0.89 (0.60-1.33)
>45 Years	236	107	129	Reference
Sex
Male	285	148	137	<0.0001**	3.10 (1.93-4.96)
Female	120	31	89	Reference
Education
≤ High School Education	278	150	128	<0.0001**	3.87 (2.40-6.25)
> High School Education	127	29	96	Reference
Occupation
≤ Skilled	294	127	167	0.509	0.86 (0.55-1.33)
> Skilled	111	52	59	Reference
Socioeconomic Status
Upper/Middle	259	113	146	0.600	0.89 (0.59-1.34)
Lower	146	69	80	Reference
Marital Status
Married	348	148	200	0.096	0.62 (0.35-1.08)
Unmarried/Seperated/Divorced/Widow	57	31	26	Reference
Family Type
Nuclear Family	312	161	151	<0.0001**	4.32 (2.46-7.58)
Joined/Three Generation Family	93	18	75	Reference
Age of initiation of tobacco use
<30 Years	231	145	86	<0.0001**	6.94 (4.38-10.99)
≥ 30 Years	174	34	140	Reference
Duration of tobacco use
≥10 Years	168	107	61	<0.0001**	4.01 (2.64-6.11)
<10 Years	237	72	165	Reference
Frequency of usage/day
≥10 times	318	140	178	0.893	0.96 (0.60-1.55)
<10 times	87	39	48	Reference
Tobacco usage among Family members
Yes	250	101	149	0.055	0.66 (0.44-1.01)
No	155	78	77	Reference

Whereas in univariate analysis, psychological nicotine dependence was significantly associated with Male gender (P value - <0.0001, OR – 4.13), marital status (P value - <0.0001, OR – 4.83), ≥ 10 Years of tobacco use (P value - <0.0001, OR – 2.81), consuming tobacco ≥10 times in a day (P value - 0.011, OR – 1.91) [Table 4].

Table 4.

Association between psychological nicotine dependance and selected factors among the study population (n – 405)

Variable	Total frequency	Psychological dependance to nicotine
		Yes (295)	No (110)	P	Odds ratio (95% CI)
Age
≤45 Years	169	120	49	0.482	0.85 (0.54-1.32)
>45 Years	236	175	61	Reference
Sex
Male	285	234	51	<0.0001**	4.13 (2.54-6.64)
Female	120	61	59	Reference
Education
≤ High School Education	278	201	77	0.719	0.91 (0.56-1.47)
> High School Education	127	94	33	Reference
Occupation
≤ Skilled	294	213	81	0.773	0.93 (0.56-1.52)
> Skilled	111	82	29	Reference
Socioeconomic Status
Upper/Middle	259	186	73	0.537	0.86 (0.54-1.37)
Lower	146	109	37	Reference
Marital Status
Married	348	271	77	<0.0001**	4.83 (2.69-8.67)
Unmarried/Seperated/Divorced/Widow	57	24	33	Reference
Family Type
Nuclear Family	312	224	88	0.387	0.78 (0.46-1.35)
Joined/Three Generation Family	93	71	22	Reference
Age of initiation of tobacco use
<30 Years	231	165	66	0.462	0.84 (0.54-1.32)
≥30 Years	174	130	44	Reference
Duration of tobacco use
≥10 Years	168	141	27	<0.0001**	2.81 (1.72-4.59)
<10 Years	237	154	83	Reference
Frequency of usage/day
≥10 times	318	241	89	0.011*	1.91 (1.15-3.16)
<10 times	87	54	21	Reference
Tobacco usage among Family members
Yes	250	180	70	0.629	0.89 (0.56-1.40)
No	155	115	40	Reference

Binary logistic regression was done using enter method. High physical nicotine dependance was significantly associated with male gender (P value - 0.016, OR – 1.20), age of initiation of tobacco use <30 Years (P value - <0.0001, OR – 2.55), and ≥ 10 Years of tobacco use (P value - <0.0001, OR – 2.71). Psychological nicotine dependance was associated with Male gender (P value - <0.0001, OR – 3.02) and ≥ 10 Years of tobacco use (P value - <0.0001, OR – 2.12) [Table 5].

Table 5.

Binomial logistic regression analysis findings

Variable	High Physical Nicotine Dependance
	P	Adjusted Odds Ratio (AOR)	95% CI
Male gender	0.016	1.20	1.05 – 1.44
≤ High school education	0.235	0.80	0.567-1.149
Nuclear Family	0.397	0.93	0.567-1.149
Age of Initiation o tobacco use (30 Years)	<0.0001	2.55	1.806-3.505
≥ 10 Years of tobacco use	<0.0001	2.71	1.958-3.756
Variable	Psychological Nicotine Dependance
	P	Adjusted Odds Ratio (AOR)	95% CI
Male gender	<0.0001	3.02	1.81-4.78
Marital status	0.094	0.89	0.59-1.34
≥10 Years of tobacco use	<0.0001	2.12	1.958-3.756
Tobacco use of ≥10 times in a day	0.101	0.71	0.48-1.23

Discussion

In our study, 70.1% were males and 270 (66.7%) use smoked form of tobacco. About 44.1% and 29.6% had high and moderate physical dependence respectively. Also, 31.3% had mild psychological dependence. In binary logistic regression analysis, high physical nicotine dependance was significantly associated with male, age of initiation of tobacco use < 30 Years, and ≥ 10 Years of tobacco use. Psychological nicotine dependance was associated with male gender and ≥ 10 Years of tobacco use. The results obtained were in accordance with other studies.

Mean age of the study population was 36 ± 11.2 Years The mean age was 32.7 ± 8.12 years in a study conducted in Western India by Divinakumar et al.[13] In Jonas et al.[16] study 49.56 ± 13.4 years was the mean age of the study population. Majority of them were males accounting to 70.1% in this study which was in accordance with other studies.[17,18] Whereas female preponderance (53.5%) was seen in studies by Jonas et al. and Janakiram et al. in these studies females accounted for 53.5% and 58.3% respectively.[16,19]

About 66.7% of them use smoked form of tobacco and about 1/4^th started to use tobacco before the age of 20 years. Around 21.7% were using tobacco for ≥ 10 Years and nearly half of the study participants use tobacco for ≤ 5 times in a day in our study. In Janakiram et al.[19] study, 82% use smokeless tobacco, 6.2 years and 5.3 years were the mean frequency of smokeless tobacco use and smoking per day. About 21.9% were smokers, 57.4% were started using tobacco in 11-15 years of age, and 70.2% were using tobacco for more than 20 years in a study by Islam et al.[20] In Jonas et al.[16] study mean age of starting tobacco use was 22.4 ± 9.2. Mean pack years of smoking was 26.6 ± 20.6 and 20.7% were current smokers. Median age of starting tobacco usage was 16 years, and median duration of smoking was 10 years in Aryal et al.[21] study. Shamsi et al.[22] study conducted in Pakistan found out that 59.5% find it difficult to search for smoking areas and 21.6% had a family or friend who uses tobacco.

Among the tobacco users of this study, 44.1% and 29.6% had high and moderate physical nicotine dependence respectively. Similar to our study in Roberts B et al.[23] study about 24.9% had low dependance, 33.7% had moderate dependance, and 44.4% had high nicotine dependance. Heydari GR et al.[24] study reported that 55.2% had high nicotine dependance, 33.5% had moderate dependance and 11.3% had low dependance. On the contrary, our study results were not in accordance with the findings of studies by Priyanka et al., Rushender et al., and Meghea et al.[25,26,27] This might be attributed to the differences in the sociodemographic characteristics, study setting, cultural habits, and study tool used.

In this study, 31.3% and 13% had mild and high psychological nicotine dependence. Whereas, 27.2% of them had no psychological dependence to tobacco. Similar to our study about 75.4% had psychological dependance to nicotine in Margaritis et al. study.[28] In a German study by Hoch et al.,[29] 47% of the smokers were psychologically dependant to nicotine. Nearly 61.2% of the smokeless tobacco users and 16% of the smokers were psychologically dependant on nicotine in Deolia et al. study.[14]

High physical nicotine dependance was significantly associated with male gender, age of initiation of tobacco use < 30 Years, and ≥ 10 Years of tobacco use Similar to our study, in Jonas et al.[16] study, duration of smoking, age of initiation of tobacco use, and type of tobacco use were associated with nicotine dependance. Male gender, younger age group, lower educational status were significantly associated with nicotine dependance in Picco et al. study.[30] Divinakumar et al. study found out that Age (31-34 years), lower socioeconomic status, duration of tobacco use, and type of tobacco use were associated determinants of physical dependance.[13] Whereas in Manimunda et al.[31] study Age, current alcohol use, socioeconomic status, marital status, and presence so comorbidities were the determinants of nicotine dependance.

Psychological nicotine dependance was associated with Male gender (and ≥ 10 Years of tobacco use in our study. In Margaritis et al.[28] study, Younger age (18-24 years), female sex, and individuals in lower educational groups are less prone to develop nicotine dependance. Age and education were the two variables associated with psychological dependance in a study by Deolia et al.[14] which is in contradiction to our study findings.

Conclusion

From the findings of the study, it can be concluded that the prevalence of nicotine dependance was high in the study area. Even though many legislative measures and acts were passed by the government to address this problem there are few lacunae identified in this study. All these lacunae must be bridged by effective interventions. Early diagnosis and treatment of nicotine dependance, prevention of complication through the healthcare professionals will enhance the quality of life of affected people.

Lifestyle modification plays a key role in nicotine dependance and change in the harmful lifestyle habits must be adopted. The target population for this strategy will be adolescents and early adults. Counselling, motivation, and encouragement from the community will surely help tobacco users in quitting tobacco and also prevent relapse. Government should strict enforcement of the available acts against tobacco usage. Prohibition of tobacco sale near schools, sale of tobacco to minors, banning advertisements promoting tobacco use, and legal actions must be taken on hose using tobacco in public places.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.