Smokeless Tobacco (SLT) Consumption Behavior and Associated Socio-Demographic Factors Among Bangladeshi Dental Patients

Abstract

Introduction: Oral consumption of smokeless tobacco (SLT) is associated with poor periodontal health and a range of oral diseases, some of which are malignant or potentially malignant. This research aims to ascertain whether a certain socio-demographic category of individuals with any type of oral syndrome has a higher likelihood of using and consuming smokeless tobacco in specific ways. Method: A tertiary dental institution in Dhaka conducted cross-sectional research on adult oral hygiene patients from April 2024 to September 2024. A semi-structured questionnaire was replied by 156 research participants. Purposive sampling was used to choose study participants who were at least 18 years old, SLT users, and had at least ten natural teeth. Results: There might not be any gender disparity in the SLT intake because this study was conducted at the outdoor department of a tertiary dental facility with patients from a range of socio-demographic backgrounds. All the socio-demographic variables, including age, gender, marital status, number of children, family size, and employment, found to be significantly (P ≤ 0.05) associated with consumption of SLT along with smoking. Living location and education were the only exceptions. However, the length of time a person has consumed smokeless tobacco is affected by his/her socio-demographic factors such as age, residence region, marital status, number of family members, and number of children substantially (P ≤ 0.05). Conclusion: A coordinated and collaborative initiatives aimed at reducing smokeless tobacco consumption and smoking is required to prevent dental health degradation, especially among the vulnerable groups (eg, women, the elderly, residents of rural areas).

Introduction

Smokeless tobacco (SLT) is a prevalent tobacco-consuming form. It was popular in Asian countries and also in Africa. During the 20th century, it emerged in the USA and European countries. ¹ Usually, SLT is consumed nasally or orally (without burning). Oral SLT goods are consumed by chewing as loose leaf, plug, or twist form. Snuff is another form (powdered) of SLT that can be taken as moist or dry, and consumed orally by applying to the teeth or gums. Dry one can be also inhaled nasally. ² Nicotiana tabacum and N Rustica are used for most SLT products. Along with other tobacco alkaloids, nicotine is about 85-95% of total alkaloids in SLT. Mainly leaves with stems are blended to gain nicotine content, pH, and flavor. Worldwide, various SLT products are consumed usually consumed only or with other products. The occurrence of SLT consumption can vary noticeably across the countries, and also within the countries.

Tobacco use has been proven as one of the predominant public health concerns that the whole world has ever challenged. Around six million losses a year are responsible for the frequent use of tobacco. ³ The ease of getting processed or unprocessed forms of raw tobacco goods also leads Bangladesh to the worst position that possibly exposes the underprivileged people further to the health risks of SLT goods. Several toxic, mutagenic, and carcinogenic constituents were reported to be present in those products of SLT. ⁴ The lack of awareness and knowledge on the critical effects of SLT are the key reasons to be exposed to addictive smokeless tobacco use. Smokeless tobacco consumption is related to numerous adverse health consequences such as cancer, hypertension, cardiovascular disease, and many other diseases including life-risk complications during pregnancy as well as different antagonistic results of pregnancy. ⁵

Some states of South Asia are the main tobacco producers and net exporters. About 90% of the world’s smokeless tobacco consumers live in South-East Asia. In Bangladesh, India, Pakistan, and Sri Lanka, men as well as women are habituated culturally in the consumption of SLT as the form of betel quid. ⁶ Among the countries of South Asia, the position of Bangladesh as a tobacco grower is also central. In this country, tobacco leaves are easily accessible for use as smokeless tobacco. ⁷ In Bangladesh, the usual forms of SLT intake are betel quid, tooth powder (tobacco), and tobacco with lime. In any small and large social get-togethers, it is customary to use SLT in the form of betel quid after having the food. ⁸ A chewable form of smokeless tobacco use is a pervasive form of SLT consumption in Bangladesh. Women about 39%, and men about 22% were reported to practice that form of SLT in this country. ⁹ Not only men and women but young and children are also habituated to several newly packed forms and flavored forms of smokeless tobacco products. Usual forms such as Sada–pata (sun-dried, typically at home), Gul, and Zorda (processed industrially), are economical, and thus amounts of use are comparatively higher in low-earning urban entities. ¹⁰ As these products are beyond the concern of regulatory authorities there is no warning on the label about the constituents such as nicotine percentage as well as its health risks. Adversely, there are public misunderstandings amongst diverse demographic regions of people in Southeast Asia as well as Bangladesh that this form of tobacco consumption is not as unsafe as cigarettes and worth it for the gums and teeth thus subsequently being used in the form of Gul (dentifrice). ¹¹ Because of such misrepresentation of chewing SLT, a large number of people practice it to clean teeth, as an oral refresher, and to get relief from several pains. Some users keep betel quid in touch with the oral mucosa used for prolonged periods, even the whole night.

Consumption of this form of tobacco varies with gender, age, indigenous origin, and socioeconomic features. ¹² Intake of SLT with the mixture of betel leaf, slaked lime, areca nut, and some spices (known as betel quid) has been now integrated into the cultural life in some countries which is the most frequently used form of smokeless tobacco. The occurrence of smokeless tobacco usage was revealed as more in the rural areas and was advanced amongst socioeconomically underprivileged people. ⁴ Though the mouth is the access to a health condition, we infested this entry by using SLT (Zarda and Gul). ¹³ More than twenty-seven percent of adults 15 years old or older than this age practice smokeless tobacco in Bangladesh and the usage of smokeless tobacco is correlated with the sociodemographic status of the individual. The Occurrence of health risks such as oral cancer, stroke, and heart disease has increased reflected in the life loss of about three lacks and twenty thousand within 2010 in Bangladesh. ¹⁴

A few studies are known that focused on the exposure of a particular sociodemographic group to smokeless tobacco ingestion behaviors and allied health values, mostly targeted to rural and underprivileged populations.^8,13 The worldwide prevalence of oral cancer is increasing and about seven thousand subjects are identified yearly in Bangladesh. ¹⁵ Therefore, the objective of this study was to determine the association of sociodemographic characteristics and smokeless tobacco consumption behavior among dental patients.

Methods

Study Design

It was a cross-sectional study conducted from 24 April 2024 to 15 September 2024.

Study Sample

All the participants were patients attending outdoor services (OPD) of the selected tertiary dental hospital named, Dhaka Dental College and Hospital. The sample size was determined using a single proportion formula for a population, $\mathrm{n}=\left(\mathrm{z}\right)^2\mathrm{p}\left(1-\mathrm{p}\right)/\mathrm{W}^2$ where, n = desired sample size, when the study population >10 000, Z is the standard normal distribution set as 1.64, which corresponds to a 90% confidence interval. P = .80 (Prevalence of oral effects due to SLT consumption).^16,17

$$1-\mathrm{P}=\left(1-0.80\right)=0.20$$

Based on this- n = (1.64)_^2*(0.80)*(0.20)/(0.05)_^2 = 172

Sample size was estimated 172, however, 156 participants were included in the study by Purposive sampling method, due to incomplete response by the remaining participants.

Selection Criteria

Dental patients of 18 years and above with at least 10 natural Teeth, who visited at the Outdoor department in the selected dental hospital for treatment were the population of the study. Apparently healthy dental patients both smokers and non-smokers, who consume either form of smokeless tobacco were included for this study. Patients less than 18 years, and who were not willing or/and unable to attend the survey questionnaire administration due to physical or mental causes were excluded.

Data Collection Tool and Methods

A semi-structured questionnaire was prepared which comprised items focusing on socio-demography, smokeless tobacco-using behavior, oral hygiene-related clinical information, and duration of SLT Taking, including “WHO Oral health assessment form for adults 2013”. ¹⁸ To validate, the prepared questionnaire was pilot-tested among 16 randomly selected participants (10% of the sample size) among selected population, prior to the main survey and adjusted some of the coding categories of the variables for collecting data from included participants. Data were collected by both interviewing and self-administration depending on the patient’s educational status.

Data Quality Control Measures

The questionnaire was translated into Bengali and back-translated to English to conform to its original meaning and to maintain an unbiased response. The filled questionnaire was checked daily for completeness. The questionnaire was evaluated for its content and modification was done for some literacy questions by adding oral health status questions specific to our society to the relationship between oral hygiene and smokeless tobacco related questionnaire.

Data Analysis Method

All of the interview data was double-checked for mistakes, then coded into the database and analyzed by using statistical software named IBM SPSS (version 25.0), and IBM SPSS AMOS (version 25.0). The study objectives were the focus of the analysis, and so were the indicators. To evaluate the association among variables, we used statistical tests such as Fisher’s exact χ2 test, Structured equation modelling (SEM) including specific path coefficients of the association of the variables.

Ethical Considerations

The study protocol was reviewed and approved by the Ethical Review Committee of the Faculty of Health and Life Sciences, Daffodil International University (DIU), Dhaka, ethical approval Number: FHLS-REC/DIU/2024/0007. Permission was also taken from all the educational institutions of the participants responded in the study. Additionally, during survey, after a brief explanation of research objectives and methods, written informed consent were taken before interview from each study participant.

Results

There were variety in socio-demographic characteristics of the participants (Table1). The mean participant age is 51 years with a standard deviation of 12.77 which shows that most participants were around the mean age, while the 38% were 60 or above. The numbers of family members were in average 5 (+/−1.93), suggests that most of them, have a number of family members close to 5, while around 12% with less than 3 family members and only 9.6% were with over 8 persons. Among the participants the male to female ratio was 55% and 45% respectively. Majority (58.3%) of the participants were urban residence and 41.7% from rural areas. With 44% illiterate participants, there were only around 21% participants who completed more than secondary level education. Which also reflects the occupation among participants, where 39% were with labor-based work and only 5% with official job, 17.3% with business, and 21% homemakers (Table 1).

Table 1.

Frequency Distribution of the Socio-Demographic Characteristics.

Variable	Categories	Frequency (percent)
Participant’s age	Below 40 years	50 (32.10%)
	40 to 49 years	17 (10.90%)
Mean = 51.13	50 to 59 years	30 (19.20%)
SD = 12.77	60 or above years	59 (37.80%)
Number of family members	Less than 3	19 (12.20%)
	4 to 5	72 (46.20%)
	6 to 7	40 (25.60%)
Mean = 5.22	7 to 8	10 (6.40%)
SD = 1.93	More than 8	15 (9.60%)
Participant’s gender	Female	70 (44.90%)
	Male	86 (55.10%)
Participant’s educational level	Illiterate	69 (44.20%)
	Primary	23 (14.70%)
	Secondary	29 (18.60%)
	Higher secondary	18 (11.50%)
	Graduate or more	17 (10.90%)
Participant’s occupation	Student	12 (7.70%)
	Private/public job	8 (5.10%)
	Business	27 (17.30%)
	Homemaker	33 (21.20%)
	Self employed (labor-based work)	61 (39.10%)
	Unemployed	15 (9.60%)
Type of living area	Urban	91 (58.30%)
	Rural	65 (41.70%)
Participant’s marital status	Married	13 (8.30%)
	Unmarried	137 (87.80%)
	Widowed	5 (3.20%)

This sample of data varies widely in behavior and characteristics of SLT consumption (Table 2). Family history of SLT consumption shows that, a significant amount (around 38%) of the participants have had it. The mean age of SLT consumption initiation was 31 years (SD 10.69), showing a wide variation in initiation age, while majority of them started having SLT in between 15 to 45. Regarding the type of SLT consumption, participants showed a wide variety, while combination of “Supari, Chun, Khowar” (36.5%), Zarda with Gul (11.5%) and with Sada pata (10.3%), only Gul (14.7%), and only Sada pata (14.7%) were most frequent. Participants have an average frequency of smokeless tobacco use-per day — some 5 times — and with wider variation (4.48) while majority consume SLT less than 5 times in a day and around 11% over 10 times. Finally, the duration of smokeless tobacco use is 13 years on average, with a standard deviation of 7.81, suggesting that subjects have a variety of times since initiation. Where, over 70% of the participants have SLT consumption habit for more than 10 years. There were 23.7% participants who smoke cigarette along with SLT use (Table 2).

Table 2.

Frequency Distribution of the Information Regarding SLT Consumption Behavior.

Variable	Categories	Frequency (percent)
Family history of smokeless tobacco use	No	97 (62.20%)
	Yes	59 (37.80%)
Current smokeless tobacco users in the family	No one	78 (50.00%)
	At least one	77 (49.40%)
Age of smokeless tobacco initiation	<15	8 (5.10%)
	15-24	31 (19.90%)
	25-34	70 (44.90%)
Mean = 30.74	35-44	27 (17.30%)
SD = 10.69	45+	20 (12.80%)
Types of smokeless tobacco use	Supari, Chun, Khowar	57 (36.50%)
	Zarda, Sada Pata, Gul	6 (3.80%)
	Zarda, Pan masala	1 (0.60%)
	Zarda, Sadapata	16 (10.30%)
	Zarda, Gul	18 (11.50%)
	Pan masala	4 (2.60%)
	Gul	28 (17.90%)
	Sada Pata	23 (14.70%)
	Zarda	3 (1.90%)
Number of smokeless tobacco uses per day	Less than 5	95 (60.90%)
	5 to 10	43 (27.60%)
	11 to 15	11 (7.10%)
Mean = 5.40	16 to 20	4 (2.60%)
SD = 4.48	20+	3 (1.90%)
Duration of smokeless tobacco use	1 to 5 years	44 (28.20%)
	6 to 10 years	28 (17.90%)
	11 to 15 years	21 (13.50%)
Mean = 12.57	16 to 20 years	19 (12.20%)
SD = 7.81	>20 years	44 (28.20%)
Smoke tobacco with smokeless tobacco	Yes	37 (23.70%)
	No	119 (76.30%)

Table 3 presented the oral health issues among the participants. About 81% of the participants hade tooth cavities, 75% with dental prosthetics and about 24% were missing tooth due to cavities.

Table 3.

Frequency Distribution of the Information Regarding Oral Health Condition.

Variable	Category/option	Frequency (percent)
Presence of teeth cavities	Yes	126 (80.80%)
	No	30 (19.20%)
Presence of fixed dental prosthetics	Yes	38 (24.40%)
	No	118 (75.60%)
Presence of missing teeth due to cavities	Yes	37 (23.70%)
	No	119 (76.30%)

Table 4 presents an analysis of the concurrent consumption of cigarettes and Smokeless Tobacco (SLT) about various socio-demographic factors. Notably, gender plays a significant role, with a substantially higher proportion of males (48.57%) engaging in this behavior compared to females (3.49%). Additionally, marital status appears to be linked, as unmarried individuals (61.54%) exhibit a greater likelihood of consuming both cigarettes and SLT, followed by married individuals (21.01%), and widowed individuals (0.00%). The number of children in a family is also associated with this behavior, with those having one child (20.00%) or more than four children (12.50%) showing a higher inclination. In terms of age, individuals below 40 years (38.00%) are more prone to engage in this behavior, while those aged 40 to 49 years (11.76%) have a lower likelihood. Family size demonstrates significance, with individuals in families of 4 to 5 members (33.33%) being more inclined. Occupation is notably influential, with students (62.50%) and self-employed laborers (60.00%) showing higher engagement in this combined consumption. In summary, these findings provide valuable insights into the complex interplay between socio-demographic factors and the consumption of both cigarettes and SLT, highlighting specific demographic groups where targeted interventions may be beneficial in reducing such behaviors.

Table 4.

Association Between Socio-Demographic Status and SLT Consumption With Smoking.

Variable	Consumption with cigarettes		Total	Chi-square	P-value
	Smoker	Non-smoker
	n (%)	n (%)	n (%)
Participant’s age
Below 40 years	19 (38.00)	31 (62.00)	50 (32.05)	10.489	0.015
40 to 49 years	02 (11.76)	15 (88.24)	17 (10.90)
50 to 59 years	08 (26.67)	22 (73.33)	30 (19.23)
60 or more years	08 (13.56)	51 (86.44)	59 (37.82)
Participant’s gender
Male	34 (48.57)	36 (51.43)	70 (44.87)	43.351	0.000
Female	03 (03.49)	83 (96.51)	86 (55.13)
Types of living area
Urban	22 (24.18)	69 (75.82)	91 (58.33)	0.025	0.874
Rural	15 (23.08)	50 (76.92)	65 (41.67)
Participant’s marital status
Unmarried	08 (61.54)	05 (38.46)	13 (08.33)	12.390	0.005
Married	29 (21.01)	109 (78.99)	138 (88.46)
Widowed	00 (0.00)	05 (100.00)	05 (03.21)
Number of children
One	03 (20.00)	12 (80.00)	15 (09.62)	18.694	0.002
Two	14 (30.43)	32 (69.57)	46 (29.49)
Three	06 (20.69)	23 (79.31)	29 (18.59)
Four	00 (0.00)	16 (100.0)	16 (10.26)
More than four	04 (12.50)	28 (87.50)	32 (20.51)
No children	10 (55.56)	08 (44.44)	18 (11.54)
Family member
Less than 3	02 (10.53)	17 (89.47)	19 (12.18)	11.063	0.026
4 to 5	24 (33.33)	48 (66.67)	72 (46.15)
6 to 7	10 (25.00)	30 (75.00)	40 (25.64)
7 to 8	00 (00.00)	10 (100.00)	10 (06.41)
More than 8	01 (06.67)	14 (93.33)	15 (09.62)
Participant’s educational level
Illiterate	18 (26.09)	51 (73.91)	69 (44.23)	5.792	0.215
Primary	07 (30.43)	16 (69.57)	23 (14.74)
Secondary	02 (06.90)	27 (93.10)	29 (18.59)
Higher secondary	05 (27.78)	13 (72.22)	18 (11.54)
Participant’s occupation
Graduate or more	05 (29.41)	12 (70.59)	17 (10.90)	41.096	0.000
Unemployed	03 (25.00)	09 (75.00)	12 (07.69)
Student	05 (62.50)	03 (37.50)	08 (05.13)
Private/public job	07 (25.93)	20 (74.07)	27 (17.31)
Business	13 (39.39)	20 (60.61)	33 (21.15)
Housewife	00 (0.00)	61 (100.00)	61 (39.10)
Self-employed (lobor-based work)	09 (60.00)	06 (40.00)	15 (09.62)

Table 5 provides valuable insights into the relationship between the duration of Smokeless Tobacco (SLT) usage and various socio-demographic factors. It examines how individuals in different groups of these factors tend to use SLT over varying periods. First, it considers gender, revealing that SLT usage duration is not significantly influenced by gender, as indicated by the non-significant P-value of .655. Similarly, the living area does not appear to have a significant impact, as the P-value is .025, slightly exceeding the typical threshold of 0.05. However, marital status shows a strong association with SLT usage duration, with a P-value of .001. Unmarried individuals are more likely to use SLT for longer durations compared to married or widowed individuals.

Table 5.

Association Between Socio-Demographic Status and Duration of SLT Consumption.

Variables	Duration of SLT consumption (years)					Total n (%)	Chi-square	P-value
	1 to 5 n (%)	6 to 10 n (%)	11 to 15 n (%)	16 to 20 n (%)	>20 n (%)
Age
40 to 49 years	00 (0.00)	10 (35.71)	02 (7.14)	03 (10.71)	03 (10.71)	17 (10.90)	31.945	0.010
50 to 59 years	03 (14.29)	05 (23.81)	10 (47.62)	05 (23.81)	05 (23.81)	30 (19.23)
60 or more years	05 (26.32)	02 (10.53)	06 (31.58)	36 (189.47)	36 (189.47)	59 (37.82)
Less than 3	05 (26.32)	05 (26.32)	02 (10.53)	04 (21.05)	04 (21.05)	19 (12.18)
Gender
Male	19 (27.14)	15 (21.43)	09 (12.86)	21 (30.00)	21 (30.00)	70 (44.87)	2.444	0.655
Female	25 (29.07)	13 (15.12)	12 (13.95)	23 (26.74)	23 (26.74)	86 (55.13)
Living area
Urban	30 (32.97)	18 (19.78)	16 (17.58)	19 (20.88)	19 (20.88)	91 (58.33)	11.134	0.025
Rural	14 (21.54)	10 (15.38)	05 (07.69)	25 (38.46)	25 (38.46)	65 (41.67)
Marital status
Unmarried	11 (84.62)	02 (15.38)	00 (0.00)	00 (0.00)	00 (0.00)	13 (8.33)	27.089	0.001
Married	32 (23.19)	26 (18.84)	20 (14.49)	41 (29.71)	41 (29.71)	138 (88.46)
Widowed	01 (20.00)	00 (0.00)	01 (20.00)	03 (60.00)	03 (60.00)	05 (3.21)
Number of children
One	04 (26.67)	03 (20.00)	01 (6.67)	04 (26.67)	04 (26.67)	15 (9.62)	56.789	0.000
Two	13 (28.26)	10 (21.74)	09 (19.57)	05 (10.87)	05 (10.87)	46 (29.49)
Three	08 (27.59)	06 (20.69)	07 (24.14)	07 (24.14)	07 (24.14)	29 (18.59)
Four	02 (12.50)	03 (18.75)	03 (18.75)	07 (43.75)	07 (43.75)	16 (10.26)
More than four	04 (12.50)	03 (09.38)	01 (3.13)	20 (62.50)	20 (62.50)	32 (20.51)
No children	13 (72.22)	03 (16.67)	00 (0.00)	01 (05.56)	01 (05.56)	18 (11.54)
Family member
Below 40 years	36 (72.00)	11 (22.00)	03 (06.00)	00 (0.00)	00 (0.00)	50 (32.05)	134.090	0.000
4 to 5	25 (34.72)	16 (22.22)	15 (20.83)	10 (13.89)	10 (13.89)	72 (46.15)
6 to 7	08 (20.00)	06 (15.00)	03 (07.50)	16 (40.00)	16 (40.00)	40 (25.64)
7 to 8	03 (30.00)	00 (00.00)	01 (10.00)	04 (40.00)	04 (40.00)	10 (06.41)
More than 8	03 (20.00)	01 (06.67)	00 (00.00)	10 (66.67)	10 (66.67)	15 (09.62)
Educational level
Illiterate	18 (26.09)	13 (18.84)	09 (13.04)	24 (34.78)	24 (34.78)	69 (44.23)	12.840	0.684
Primary	05 (21.74)	04 (17.39)	03 (13.04)	07 (30.43)	07 (30.43)	23 (14.74)
Secondary	09 (31.03)	04 (13.79)	04 (13.79)	08 (27.59)	08 (27.59)	29 (18.59)
Higher secondary	04 (22.22)	05 (27.78)	03 (16.67)	04 (22.22)	04 (22.22)	18 (11.54)
Graduate or more	08 (47.06)	02 (11.76)	02 (11.76)	01 (05.88)	01 (05.88)	17 (10.90)

The number of children also plays a crucial role, with a highly significant P-value of .000. Those with no children or more than four children tend to use SLT for longer durations. Age is another important factor, with a P-value of .000, indicating a significant association. Those below 40 years of age are more likely to use SLT for extended periods. Family size demonstrates significance, with a P-value of .010. Larger families tend to have individuals who use SLT for shorter durations. Lastly, the educational level does not appear to have a significant impact on SLT usage duration, with a non-significant P-value of .684. This table underscores the importance of considering socio-demographic factors when examining SLT usage duration. Marital status, the number of children, age, family size, and living area all appear to play a role in influencing how long individuals engage in SLT use. These findings can inform targeted interventions and public health campaigns to address SLT usage (Table 5).

Figure 1 and Table 6 presents the results of the structural equation model (SEM) for the relationship between socio-demographic factors (Y1) and SLT (Smokeless Tobacco) using behavior (Z). The construct “Socio-demographic Factors” is denoted by Y1, and the construct “SLT Using Behavior” is represented by Z. The path coefficient between socio-demographic factors and SLT-using behavior is 0.839. The path coefficient of 0.839 indicates a strong positive relationship between socio-demographic factors and SLT-using behavior. This suggests that as socio-demographic factors increase, there is a corresponding increase in SLT-using behavior. The positive sign of the coefficient implies that higher levels of socio-demographic factors are associated with a higher likelihood of engaging in SLT use.

Figure 1.

Association Between SLT Consumption Behaviors and Socio-Demographic Factors.

Table 6.

Specific Path Coefficients of the Association of Socio-Demographic Characteristics and SLT Consumption Behavior.

Path			Estimate	Significance	P-value
SLT using behavior	<---	Socio demographic	0.839	**	.000
Participant’s age	<---	Socio demographic	1.056	**	.000
Participant’s educational level	<---	Socio demographic	−0.112	**	.000
Participant’s occupation	<---	Socio demographic	−0.079	ns	.308
Participant’s gender	<---	Socio demographic	−0.132	*	.014
Type of living area	<---	Socio demographic	0.116	*	.047
Participant’s marital status	<---	Socio demographic	0.283	*	.004
Smoking (cigarette) along with SLT	<---	SLT use behavior	0.229	ns	.091
Duration of using SLT	<---	SLT use behavior	0.832	*	.008
Per day SLT consumption	<---	SLT use behavior	0.232	*	.050
Currently SLT users in family	<---	SLT use behavior	0.175	**	.001

[Significance of Coefficients: **: P < .001 (highly significant); *: P < .05 (Statistically significant); ns: P > .05 (not significant);].

Table 6 presents the specific association of socio-demographic factors and SLT consumption behavior through path estimation. The analysis shows that participant’s age has a significant positive effect on SLT using behavior (Estimate = 1.056, P < .001), suggesting that as participants age, their likelihood of using SLT increases. Participant’s educational level has a significant negative effect on SLT using behavior (Estimate = −0.112, P < .001), indicating that higher education is associated with a reduction in SLT use, acting as a potential protective factor. However, participant’s occupation does not have a significant effect on SLT use behavior (Estimate = −0.079, P = .308), meaning that occupation alone does not strongly influence SLT usage. Participant’s gender shows a significant negative effect (Estimate = −0.132, P = .014), suggesting that male participants are more likely to engage in SLT use than females. Type of living area has a significant positive effect on SLT use behavior (Estimate = 0.116, P = .047), indicating that individual’s living area influence the use of SLT. Participant’s marital status has a significant positive effect on SLT consumption behavior (Estimate = 0.283, P = .004), indicating that married individuals are more likely to engage in SLT use compared to those who were unmarried.

Regarding the SLT using behavior factors (Table 6), smoking along with SLT has a positive effect on SLT consumption (Estimate = 0.229), but this effect is not statistically significant. The duration of SLT use shows a significant positive effect (Estimate = 0.832, P = .008), suggesting that the longer an individual uses SLT, the more likely they are to continue its use. The per day SLT consumption has a marginally significant positive effect (Estimate = 0.232, P = .051), meaning that individuals who consume more SLT daily tend to use it more frequently, although the effect is marginal. Lastly, having current SLT users in the family has a significant positive effect on SLT using behavior (Estimate = 0.175, P < .001), indicating that individuals with SLT users in their family are more likely to engage in SLT consumption, highlighting the influence of family dynamics.

Besides, the R² indicator (Figure 1) for SLT using behavior (0.70), provides a moderate indication of explained variance, which indicates the independent variable Socio-demographic factors explain 70% of the variation of the dependent variable, SLT using behavior.

Table 7 assesses the proposed model’s fitness (Figure 1) based on various fitness indices (RMSEA, GFI, AGFI, NFI, TLI, CFI, etc.,) categorized as absolute fit and incremental fit indices. Each index is accompanied by its full name, the level of acceptance, reference comments, and comments on our findings. According to the observed values of SEM fit indices, some indices have achieved the required level, some were close to the needed level. While Chi-square values were significant and Comparative Fit Index (CFI) attained the necessary level.

Table 7.

The Fitness Indices for Structural Equation Model (SEM).

Name of category	Name of index	Index full name	Level of acceptance	Reference comments	Our findings	Comments
Absolute fit	Chisq	Discrepancy Chi-square	P > .05	Sensitive when the sample size is larger than 200	Chisq. = 51.693	Significant
					P-value = .008
	RMSEA	Root mean square of error approximation	RMSEA <0.08	Acceptable ranges are 0.05 to 0.1	0.068	The required level is achieved
	GFI	Goodness of fit index	GFI > 0.90	It is a good fit when GFI is equal to 0.95	0.937	The required level is achieved
Incremental fit	AGFI	Adjusted goodness of fit	AGFI> 0.90	It is a good fit when AGFI is equal to 0.95	0.884	Close to the required level
	NFI	Normed fit index	NFI > 0.90	It is a good fit when NFI is equal to 0.95	0.833	Close to the required level
	TLI	Tucker-Lewis index	TLI > 0.90	It is a good fit when TLI is equal to 0.95	0.877	Close to the required level
	CFI	Comparative fit index	CFI > 0.90	It is a good fit when CFI is equal to 0.95	0.918	The necessary level is attained

Discussions

This research work studied for whether the relationship between socio-demographic characteristics and smokeless tobacco (SLT) usage behavior among patients be the outdoor department of a dental tertiary hospital. This research was conducted outdoors in a tertiary dental hospital which represents patients from different socio-demographics which could be the reason for non-significant gender discrimination in SLT consumption. The study reveals that the percentage of families where at least one male member practices SLT is greater (51%) than that of families in which at least one female member (48 %) uses the same, there is no significant difference (P > .05) in the same between the male and female members. A previous study reported that smokeless tobacco intake was estimated as 29% in Bangladesh, and the prevalence is greater in females (33%) than in males (23%) which was found to be more than the national prevalence in rural areas of the country. ¹⁹ SLT consumption as a chewing form in males is lower than that of females. Gender disparity in SLT consumption was reported to differ with the socioeconomic status and also with the locality but was not reported as significant in Bangladesh as well as other Southeast Asian countries. ²⁰ Prevalence of SLT consumption is increasing as customarily in Bangladesh, there is no disapprobation of using smokeless tobacco, irrespective of whether men or women. Many people practice smokeless tobacco which is culturally not forbidden. SLT use in people of rural areas is greater than the SLT use in people of urban areas. This trend is also observed in unmarried, widows, students, and unemployed people or those who are staying at home, people of age more than 60 years, and between 40-49 years. ²¹

In this study, education was found to be not associated with SLT consumption behavior, however, variations in SLT usage due to educational factors were observed as more prominent in India (urban regions) and Bangladesh (rural regions). ²² The study finds a significant correlation (P ≤ .05) between the number of children and smokeless tobacco use as well as the family members and use of SLT. Prevalence of the SLT usage is highest in the person who had no children followed by the respondent who had four or more than four children. Similarly, the occurrence of SLT use is greater in comparatively larger family sizes rather than smaller ones. An earlier study on low socio-economic people in Bangladesh revealed that family size had a non-significant relationship with SLT usage. ¹³ This endeavor also focuses on the consumption of SLT with cigarettes (smoke form) and it reveals that all socio-demographic parameters such as gender, marital status, age, family size, no. of children, and occupation except living area, and education are significant (P ≤ .05) allied with the ingestion of cigarettes and SLT. No noticeable difference was found in the occurrence of tobacco use (smoke) between the people of rural and urban regions but the usage of SLT was higher in the people of rural areas. ²³ Another study compared the use (at home in Bangladesh) of tobacco in urban and rural zones which revealed the rural usage of smoking and smokeless tobacco is higher than the usage of urban areas. ²⁴

Regardless of gender, occupation (labor-based) is found to be associated with a higher occurrence of smoking in the studies. ²⁵ However, in this study, participant occupation showed no significance with SLT consumption. Male and unmarried respondents are more prone to use both cigarettes and SLT than female and married participants. Whereas widows show no use of both forms of tobacco together. This may be due to the cost of cigarettes and considering the social tattoos against the use of cigarettes rather than SLT products. In addition, people of age less than 40 years old, who have a family size of four to five members, and who have two children are more inclined to tobacco use both cigarettes and SLT. Students and self-employed (labor-based) are more susceptible to both forms of tobacco usage than the participants of other occupations. The existing smoking (tobacco) occurrence in Bangladeshi students (university) was reported as over 60%. ²⁶ The prevalence of SLT instigation in the Bangladeshi population (age 15-24 years) is increasing evidently. ²⁷ However, socio-demographic parameters such as age, living area, marital status, family members, and number of children significantly (P ≤ .05) vary with the duration of the use of smokeless tobacco. SEM analysis of the study found the path coefficient of 0.84 indicates a strong positive relationship between socio-demographic factors and SLT-using behavior. This suggests that as socio-demographic factors increase, there is a corresponding increase in SLT-using behavior. The positive sign of the coefficient implies that higher levels of socio-demographic factors are associated with a higher likelihood of engaging in SLT use. A comprehensive work in Pakistan accompanied by patients visiting tertiary care hospitals revealed that the ingesting of SLT was increased in the poor socio-economic group with insufficient income. ²⁸ SLT users especially older people, housewives, widows, females, illiterate, and people with poor socio-economic conditions had a noteworthy relationship with several health hazards. ¹⁹

All of these findings among a group, where 81% of the participants hade tooth cavities, 75% with dental prosthetics and about 24% were missing tooth due to cavities clearly indicates that, SLT consumption not only associated with socio-demographic factors, it also affects oral health.^13-15

Aside from a few unique findings, the study had certain limitations. As Because this was a cross-sectional study in which both the outcome and the exposure were assessed concurrently, the time-course connection between the outcome and the exposures could not be determined. The study only included patients from only one tertiary dental hospital, limiting the generalizability of the findings. While about 9.3% of the estimated participants couldn’t include for their incomplete responses. Another downside of this study was the limited number of participants due to financing and time constraints.

Conclusion

Socio-demographic variables are strongly linked with smoking cigarettes during SLT usage and the duration of SLT use. In Bangladesh, smoking and SLT may be the subjects of campaigns to increase public awareness of tobacco usage. The findings clearly indicated that, socio-demographic factors influence the SLT consumption behavior and associated with Oral health conditions. The tobacco consciousness attempts in this country might involve setting prominence on SLT as well as smoking. It can be proposed from the study that organized and collaborative efforts of the organizations, directing both smoking and smokeless tobacco use lessening and end, may be adjusted to reach a population comprising who are female, students, and ageing population. Majority of the Tobacco control plans mark mainly smoking, corresponding attempts are desirable that will also comprise smokeless tobacco usage in the tobacco regulating policy and inhibition approaches.

Appendix.

Abbreviations

SLT

Smokeless tobacco

SEM

Structural equation model.

ORCID iD

Syed Billal Hossain https://orcid.org/0000-0003-4903-3690

Ethical Statement

Ethical Approval

Ethical approval was obtained from the ethical review committee of the Faculty of Health and Life Sciences of Daffodil International University (Ref: FHLS-REC/DIU/2024/007).

Consent to Participate

All the study participants were informed about the objective of the study and their written consent was obtained. The confidentiality of the information was maintained strictly.

Data Availability Statement

Study data will be given on reasonable request.*