Abstract
Tobacco use is the leading single preventable cause of death worldwide. Every tenth adult in India currently smokes tobacco. India, in particular, grapples with a high prevalence of NCDs, surpassing previous estimations. Smoking being a well-established risk factor for NCDs it is important now more than ever to address this issue with a greater aim to alleviate the burden of NCDs in India. The study was conducted among 200 adult current cigarette smokers. Fagerstrom Test for Nicotine dependence and PHQ-9 to assess the mental health status were used. Nicotine dependence was present in 52.5% of the study participants. 152 (76%) of the study participants reported their willingness to quit smoking. The majority reported a lack of self-control and factors related to nicotine dependence as a barrier to smoking cessation. 76% of the participants had depression. A significant association was noted between nicotine dependence and depression. Current willingness for smoking cessation was found to be significant in the younger age group. A total of 74.3% of participants who were nicotine-dependent were willing to quit smoking. Individuals who had previously attempted to quit smoking were 2.7 times more likely to express a current willingness to quit. A significant proportion of current smokers are willing to quit smoking, but face multiple barriers. The younger age group and depression status were found to be significantly associated with willingness to quit. Past attempts to quit emerged as a strong predictor of current cessation intentions.
Keywords: Barriers to quit smoking, nicotine dependence, smoking, smoking cessation
INTRODUCTION
Tobacco use is the leading single preventable cause of death worldwide. More than 8 million people die from tobacco use every year.[1] Most deaths are seen to occur in low-and middle-income countries, which are often targets of intensive tobacco industry interference and marketing. In India tobacco is consumed in smoking and smokeless forms via a variety of methods. According to the Global Adult Tobacco Survey-2 (GATS-2) every tenth adult in India currently smokes tobacco.[2] In addition to lung conditions like emphysema and chronic bronchitis, smoking also increases the risk of heart disease, stroke, cancer, and chronic obstructive pulmonary disease (COPD). Smoking also increases the risk of tuberculosis and is also seen to increase the risk of developing type-2 diabetes.[3] India, in particular, grapples with a high prevalence of NCDs, surpassing previous estimations. Recent studies have highlighted the alarming rates of NCDs in Goa (diabetes = 26.4),[4] indicating a pressing need for comprehensive interventions to address underlying risk factors. Smoking being a well-established risk factor for NCDs it is important now more than ever to address this issue with a greater aim to alleviate the burden of NCDs in India.
The prevalence of current tobacco smokers in rural Goa was found to be 7.1%, amongst which 53.4% of the current active smokers planned to or were thinking about quitting.[5] If a significant proportion of smokers want to quit but struggle to do so, it may indicate gaps in the available support systems.
Tobacco contains nicotine, a highly addictive substance that makes it difficult to quit smoking. Nicotine releases dopamine which creates a feeling of pleasure and a sense of euphoria which induces cravings in regular smokers. Thus, in smokers, nicotine dependency is a substance-related condition that presents as a barrier to quitting. Professional support in the form of counseling and proven cessation medications can more than double a tobacco user’s chance of successfully quitting.[6]
Effective cessation strategies require an understanding of how people perceive the risks associated with smoking and the barriers they face in quitting. Risk perceptions include beliefs about the dangers of smoking-related health outcomes, while barriers include social, personal, and environmental factors that interfere with attempts to quit.
This study aims to explore the interplay between risk perceptions and barriers towards smoking cessation among current smokers from a rural setting in Goa. We seek to shed light on the multifaceted nature of smoking behavior and attempt to help tailor the development of targeted interventions.
MATERIALS AND METHODS
It was a community-based cross-sectional study conducted among 200 current cigarette smokers residing in the field practice area of the Rural Health and Training Centre (RHTC) Mandur-Goa. Study participants were sampled using a snowballing technique. The initial study participants were asked to refer subsequent study participants who met the selection criteria. After obtaining approval from the Institutional Ethics Committee IEC, the study was conducted for 6 months.
The study participants were current smokers (adults). Data was collected using a semi-structured questionnaire, the Fagerstrom Test[7] to assess for Nicotine dependence, and PHQ-9[8] to assess mental health status were used.
A current smoker was defined as an individual who currently smokes, either daily or occasionally, and has smoked at least 100 cigarettes in his lifetime.[9,10]
Sample size
N = [(z² × p × q)] ÷ d²
Confidence interval (z) – 95%
Sample error (d) – 0.07
Prevalence (p) – 0.534 (prevalence of current active smokers planned to or were thinking about quitting)[2]
Minimum Sample size = 196 (rounded off to 200).
RESULTS
Profile of Current Smokers: out of the 200 current smokers, the majority of the study participants (98.5%) were males and (59.5%) belonged to the age group of less than 30 years and were unmarried. It was observed that 79.5% were graduates and 51.5% had a private job [Table 1].
Table 1.
Distribution of study participants based on sociodemographic characteristics, smoking characteristics, nicotine dependence, and perceived barriers toward smoking cessation
| Study Variables | Total (n=200) | |
|---|---|---|
| Age (years) | 18–30 | 119 (59.5%) |
| 31–50 | 62 (31%) | |
| >50 | 19 (9.5%) | |
| Marital status | Unmarried | 109 (54.5 %) |
| Married | 86 (43%) | |
| Widow/Divorced | 05 (2.5%) | |
| Educational status | College and above | 159 (79.5%) |
| Secondary | 39 (19.5%) | |
| Primary | 2 (1%) | |
| Occupation | Private Job | 103 (51.5%) |
| Government Job | 33 (16.5%) | |
| Student | 29 (14.5%) | |
| Business | 11 (5.5%) | |
| Unemployed | 7 (3.5%) | |
| Farmer | 5 (2.5%) | |
| Daily wages | 5 (2.5%) | |
| Retired | 7 (3.5%) | |
| Socioeconomic Status |
Class-1 (Upper class) | 88 (44.0%) |
| Class-2 (Upper middle class) | 90 (45.0%) | |
| Class-3 (Middle class) & lower | 22 (11%) | |
| No. of Cigarettes smoked per day | <5 | 184 (92%) |
| 6–10 | 12 (6%) | |
| >10 | 4 (2%) | |
| Risk Perception of Smoking | Knowing that Smoking is harmful | 198 (99%) |
| Not knowing that Smoking is harmful | 02 (1%) | |
| Reason for Initiation of Smoking | To try | 133 (66.5%) |
| Peer pressure | 64 (32%) | |
| Stress | 51 (25.5%) | |
| Motivated after watching movies | 2 (1%) | |
| Nicotine Dependence | No dependence (score: 0) | 95 (47.5%) |
| Low dependence (score: 1-2) | 67 (33.5%) | |
| Low-moderate dependence (score: 3–4) | 31 (15.5%) | |
| Moderate dependence (score: 5–7) | 7 (3.5%) | |
| Barriers to smoking cessation | Personal and lifestyle | 164 (82%) |
| Social and environment | 58 (29%) | |
| Lack of knowledge | 39 (19.5%) | |
| Lack of support | 43 (21.5%) | |
Table 1: Distribution of study participants based on sociodemographic characteristics, smoking characteristics, nicotine dependence, and perceived barriers toward smoking cessation.
The mean age at which the participants started to smoke was 20.9 years ± 3.71. A majority of the study participants 184 (92%) smoked ≤5 cigarettes per day [mean = 3.97 ± 2.05)] [Table 1].
When asked about whether the participants ever attempted to quit smoking in the past, about 161 (65.5%) reported attempting to quit smoking in the past. 97 (45.5%) reported that lack of self-control was the major reason for their relapse after attempting to quit smoking. About 35 (17.5%) were forced to restart smoking because of their peer groups. 25 (12.5%) said that they relapsed because of a lack of knowledge about smoking cessation. 7 (3.5%) had a fear or a misconception that quitting smoking would harm their body and hence relapsed.
When asked about their current willingness to quit smoking, 152 (76%) of the participants said that they would like to quit smoking. We observed that 118 (59%) expressed a willingness to quit smoking primarily to improve their own health, 82 (41%) cited family promptings as a significant factor motivating their desire to quit.
The majority 164 (82%), said that the biggest barrier for smoking cessation they perceived would be because of their lack of self-control and factors related to nicotine dependence which were grouped as personal and lifestyle factors. Social and environmental factors which included peer group pressure or being in an environment of smokers were reported as a barrier to smoking cessation by 58 (29%). 39 (19.5%) perceived a lack of knowledge to smoking cessation as a barrier whereas 43 (21.5%) said that a lack of support by friends and family members was perceived as a barrier to smoking cessation [Table 1].
The study participants were assessed for their mental health status using the patient health questionnaire (PHQ-9). 152 (76%) of the participants had depression, wherein a majority 126 (63%) had mild depression and 26 (13%) were found to have moderate depression. Significant association was noted between nicotine dependence and depression (χ² =11.4, df = 1, P = 0.001, OR = 3.193 (1.6006–6.3719)).
The higher proportion of current smokers with depression expressing a willingness to quit may reflect various factors related to the interplay between depression and smoking. (χ² =0.924, P value = 0.336, OR = 1.429, CI = 0.6887–2.9655) [Table 2].
Table 2.
Willingness to quit smoking in different study variables
| Study Variables | Willingness to quit smoking (%) |
P | OR | CI | AOR | CI | |||
|---|---|---|---|---|---|---|---|---|---|
| Yes | No | Total (n=200) | |||||||
| Nicotine Dependence | Yes | 78 (74.3%) | 27 (25.7%) | 105 (52.5%) | 0.551 | 0.819 | 0.4267 to 1.5751 | 0.999 | 0.916 to 1.089 |
| No | 74 (77.9%) | 21 (22.1%) | 95 (47.5%) | ||||||
| Depression | Yes | 118 (77.6%) | 34 (22.4%) | 152 (76%) | 0.336 | 1.429 | 0.6887 to 2.9655 | 1.182 | 0.397 to 3.510 |
| No | 34 (70.8%) | 14 (29.2%) | 48 (24%) | ||||||
| Ever attempted to quit smoking in past | Yes | 108 (82.4%) | 23 (17.6%) | 131 (65.5%) | 0.003 | 2.668 | 1.3707 to 5.1931 | 3.844 | 1.653 to 8.950 |
| No | 44 (63.8%) | 25 (36.2%) | 69 (34.5%) | ||||||
| Initiated smoking (age) | ≤20 yrs | 76 (73.8%) | 27 (26.2%) | 103 (51.5%) | 0.450 | 0.777 | 0.4049 to 1.4942 | 0.592 | 0.092 to 3.800 |
| >20 yrs | 76 (78.4%) | 21 (21.6%) | 97 (48.5%) | ||||||
| Age Groups (yrs) |
18–30 | 99 (83.2%) | 20 (16.8%) | 119 (59.5%) | <0.001 | ||||
| 31–50 | 46 (74.2%) | 16 (25.8%) | 62 (31%) | ||||||
| >50 | 7 (36.8%) | 12 (63.2%) | 19 (9.5%) | ||||||
| Marital Status | Unmarried | 87 (79.8%) | 22 (20.2%) | 109 (54.5%) | 0.018 | ||||
| Married | 63 (73.3%) | 23 (26.7%) | 86 (43%) | ||||||
| Widow | - | 3 (100%) | 3 (1.5%) | ||||||
| Divorced | 2 (100%) | - | 2 (1%) | ||||||
| Occupation | Private Job | 86 (83.5%) | 17 (16.5%) | 103 (51.5%) | <0.001 | ||||
| Government Job | 23 (69.7%) | 10 (30.3%) | 33 (16.5%) | ||||||
| Student | 22 (75.9%) | 7 (24.1%) | 29 (14.5%) | ||||||
| Business | 11 (100%) | - | 11 (5.5%) | ||||||
| Unemployed | 7 (100%) | - | 7 (3.5%) | ||||||
| Farmer | - | 5 (100%) | 5 (2.5%) | ||||||
| Daily wages | 3 (60%) | 2 (40%) | 5 (2.5%) | ||||||
| Retired | - | 7 (100%) | 7 (3.5%) | ||||||
| Socioeconomic Status | Class-1 (Upper class) | 70 (79.5%) | 18 (20.5%) | 88 (44%) | 0.481 | ||||
| Class-2 (Upper middle class) | 67 (74.4%) | 23 (25.6%) | 90 (45%) | ||||||
| Class-3 (Middle class) and lower | 15 (68.2%) | 7 (31.8%) | 22 (11%) | ||||||
The study revealed a substantial difference in the willingness to quit smoking who had attempted to quit in the past and those who had never attempted to quit before. The odds ratio calculated for this comparison was 2.668 (CI = 1.3707–5.1931), indicating a significant association between past quit attempts and current willingness to quit smoking [Table 2].
The proportion of willingness to quit smoking was seen to be highest in the younger age group and the willingness to quit smoking declined with age and was seen to be the lowest in individuals who were above 50 years of age (36.8%) (χ² =19.5, P value < 0.001) [Table 2].
A low proportion of current smokers, i.e. 28 (14%) reported knowing about the various smoking cessation apps available online.
DISCUSSION
Worldwide attention to tobacco cessation has increased due to the substantial health benefits of doing so. Our study provided several key findings concerning cigarette smoking in a rural area of Goa. About 76% of the current smokers showed a willingness to quit smoking which was higher as compared to the 2016-17 GATS-2 data for rural Goa which was 53.4%.[5] This could be due to various reasons such as most of the study participants were educated and were aware that smoking is harmful to their health. Studies have shown higher quit attempts among people with a high socioeconomic status[11], which could be another reason for this.
Risk perception to smoking was also seen to be higher in our study, about 99% of the study participants were aware that smoking is harmful to their health and is a risk factor for various diseases compared to 2016-17 GATS-2 data for rural Goa, which was 90.5% suggesting the rising level of awareness about the harmful effects of smoking.
The mean age of initiation of smoking [20.9 yrs (SD = 3.71)] was found to be comparable (20.2 yrs) in a study done by Jindal et al.[12] Therefore, we must focus on addressing the unique challenges and vulnerabilities present at this age to intervene early and prevent the development of the habit of smoking.
A statistically significant association was noted between nicotine dependence and depression among current smokers indicating an interplay between the two conditions. Previous studies also have shown a similar association between smoking and depression[13,14] making it difficult for smokers to quit smoking.[15] Some studies have also indicated a bidirectional relationship between the two factors.[16,17] A study done by El-Sherbiny and Elsary[18] found a correlation between smoking dependence and depression.
Among current smokers who are nicotine dependent, 74.3% expressed a current willingness to quit smoking, while 77.9% of current smokers who are not nicotine dependent reported of similar intentions. Nicotine dependence is characterized by withdrawal symptoms and cravings that can make quitting smoking more challenging. Individuals who are nicotine dependent may perceive quitting as more difficult and may be less motivated to attempt cessation due to fear of withdrawal symptoms or perceived inability to quit successfully. Moreover, nicotine-dependent smokers may have made previous unsuccessful quit attempts, leading to a feeling of discouragement. A similar finding was observed in a study done in rural West Bengal where the intention to quit smoking was significantly associated with low nicotine dependence.[19]
It was also observed that a significantly higher proportion of individuals who were willing to quit smoking belonged to the younger age group of 18–30 years, suggesting that this age group is more receptive towards smoking cessation. A similar finding was observed in a study done by Islam et al.[20] wherein the younger age group was willing to quit tobacco.
The observed difference in willingness to quit smoking between individuals with and without depression highlights the potential influence of mental health status on smoking behavior. One possible explanation is that individuals with depression may be more motivated to quit smoking due to heightened awareness of the negative impact of smoking on mental health. Smoking is often used as a coping mechanism for managing stress and negative emotions,[21] but individuals with depression may recognize the detrimental effects of smoking on their mental well-being and be more inclined to quit as a result.[22]
Our study found that individuals who have previously attempted to quit smoking are approximately 2.7 times more likely to express a current willingness to quit compared to those who have never attempted to quit. The substantially higher proportion of current smokers willing to quit among those who attempted to quit smoking in the past suggests that past experiences play a pivotal role in shaping a smoker’s readiness to give up the habit. Several factors may contribute to this observed association. Firstly, past quit attempts may serve as a learning experience in smoking cessation. Individuals who have previously attempted to quit may have developed some kind of coping mechanism or accessed support services that increase their confidence and motivation to try again. Additionally, repeated exposure to the health risks and social stigma associated with smoking may further strengthen their desire to quit among those who have made attempts to quit smoking in the past.
A low proportion of current smokers knew about the availability of various smoking cessation applications online, suggesting a significant gap in the dissemination or utilization of digital resources aimed at supporting smoking cessation efforts.
With a prevalence of cigarette smoking being at 4.1%[5] in rural Goa, among the estimated population of 380,000 in rural Goa as per the Economic Survey 2022-2023, there are over 15 thousand current active cigarette smokers in rural Goa and as per the findings of our study, wherein 76% of current smokers expressed of their willingness to quit smoking is suggestive of a significant level of readiness for behavioral change among the smoking population in the region. Thus, by capitalizing on this willingness and addressing associated barriers we could effectively reduce tobacco use improve the overall health and well-being of the population, and progress toward making Goa a smoking-free community.
CONCLUSION
This study highlights associations between various factors and willingness to quit smoking among current smokers. The reported barriers such as nicotine dependence, social and environmental factors, and stress, underline the multifaceted nature of this challenge. Through our study, we would like to suggest that effective smoking cessation interventions must adopt a holistic approach combining different strategies such as pharmacological treatments, behavioral support, and tailored counseling. It is imperative to prioritize capacity building within health and wellness centers to effectively address smoking cessation activities. Equipping these centers with the necessary resources, training, and support systems, shall enhance their ability to deliver comprehensive smoking cessation interventions and increase awareness of cessation services to address the diverse needs of smokers who are willing to quit and reduce the burden of tobacco-related diseases as a whole, ultimately contributing to the mitigation of NCDs and the promotion of public health and wellness in India.
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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