Assessment of anxiety, depression and nicotine dependence among construction workers in Chennai - A cross sectional study

Abstract

Background

Tobacco dependence has been identified as one of the important public health problems faced by both developing and also the developed countries. Anxiety and depression might also influence the quality of life of the tobacco users which increases the dependence on nicotine.

Materials and methods

The study was conducted among male construction workers with the habit of tobacco (production workers and labourers) in Chennai who were all working under different organizations from June 15, 2021 to August 15, 2021(n = 416). GAD-7 anxiety severity questionnaire, Patient Health Questionnaire-9, Fagerstrom test for nicotine dependence was used to collect the data. Statistical analysis was done using Statistical Package for the Social Sciences Version 23.

Results

Since the data is normally distributed, Parametric tests have been carried out. A highly statistically significant difference (p = 0.00) was found on finding the association of fagerstrom nicotine dependence with the groups (smokers, smokeless and both users) from One-way ANOVA test. A positive correlation was found between nicotine dependence, GAD-7(r = 0.82) and PHQ-9(r = 0.79).

Conclusion

Nicotine dependence plays a vital role in an individual's anxiety and depression level. Higher the nicotine dependence higher their anxiety and depression level. Long working hours also plays an evident role which influences workers mental health directly.

Graphical abstract

1. Introduction

Tobacco use is a threat aspect for six of the eight main causes of demise. Tobacco dependence has been identified as one of the important public health problems faced by both developing and also the developed countries. Moreover, more than one third to half of the tobacco users were sick or dead in recent days. To be precise, the lifespan of every tobacco user decreased by 15 years of their life.¹ The total range of tobacco-attributable deaths - from anemia, heart condition, carcinoma and alternative diseases - was estimated to rise from five.4 million in 2004 to 8.3 million in 2030.² Nicotine along with more than 4000 chemicals were present in every type of tobacco like cigarette, cigar, pipe tobacco, snuff, and chewing tobacco which is addictive immensely and also immediately absorbed into the bloodstream.³

As smoking was very common among the construction workers, specifically adolescents, smoking cessation should be an immediate concern for workers in India. Many non-governmental organizations and associations were actively conducting smoking cessation education and anti-smoking campaigns and many other programmes like creating an anti-smoking space such as regulations on nicotine advertisements, warning signs in opposition to smoking and forbidding nicotine sale to people below 18 years.^4,5 In Spite of all the efforts the major cause of increase in tobacco users is their dependence on nicotine which is present in tobacco.⁶Usually smoking always has a deep connection with their lifestyle and social factors.⁷ To be precise it also has a relationship with their job stress, anxiety and depression. Most common method to determine nicotine dependence is Fagestrom's Nicotine Test for Dependence- Smoking and Smokeless consisting of 6 questions.⁸ FTND is a statistically proven instrument for estimating the seriousness of nicotine dependence as it has been used in many studies.

Anxiety and depression might also influence the quality of life of the tobacco users which increases the dependence on nicotine. Stress & strain among construction workers were due to workload, fixed time frame, lack of training, poor communication among workers as well as with supervisors which may affect their oral health and increased smoking behavior too.^9,10

This is the first study to my knowledge in South India which address the relationship between depression, anxiety and nicotine dependence. In this study construction workers have been selected as the target population as most of the workers were users of tobacco which we have found out through an oral health screening camp. Their lifestyle, living environment, migration without any basic facilities and living away from home make them more susceptible to nicotine dependence. This made us to analyses the relationship between depression, anxiety and their nicotine dependence according to their demographic and occupational characteristics in order to reduce the smoking related to stress which will help to develop indicators for smoking cessation strategies.

2. Materials and methods

2.1. Study population

The study was conducted among male construction workers with the habit of tobacco (production workers and labourers) in Chennai who were all working under different organizations from June 15, 2021 to August 15, 2021(n = 416). Workers were selected through the multistage sampling method. Chennai was divided into 5 major zones as Chennai North, South, West, East and Central and from each zone a major construction site was selected from the cluster and from there workers were selected randomly who were present during the day of which study was conducted. The study was approved by the Institutional Review Board of Saveetha University. Informed consent was collected before the start of the study. The study purpose and its theme was clearly explained to the study participants. Anonymity of the participants was maintained and no personal information of the participants was included in the survey. Sample size was calculated as 416 workers using the previously published article⁴ by keeping 95% confidence interval and 5% of type II error using G power version 3.0 software.

Before the start of the study, two examiners were standardised and calibrated in the Department of Public Health Dentistry, Saveetha Dental College, Chennai to ensure uniform interpretation, understanding and application of codes used in the study. Examiners were named as Examiner A and Examiner B and underwent training for a day. They were trained to record GAD-7 and PHQ-9 which contain 7 and 9 closed end questions respectively regarding anxiety and depression and also Fagerstrom test for Nicotine dependence (Smoking and Smokeless) which contains 6 close ended questions each.

2.2. Inclusion and exclusion criteria

• -Workers who were current tobacco users(smokeless or smoking form) were included in the study
• -Tobacco users who were present on the day of data collection were included
• -Tobacco users who were former tobacco users and users with systemic diseases were excluded from the study
• -Tobacco users who were under nicotine replacement therapy and not agreed to participate in the study were also excluded from the study

2.3. Survey tool

A pre validated and tested questionnaire containing 4 parts in which first part has demographic details which includes age, gender, academic qualification divided into illiterate, middle school, high school and college, marital status includes married and single, working hours and it also includes questions about basic smoking characteristics like duration of initiation of tobacco usage and form of tobacco usage, Second part contains standardized GAD-7 Anxiety Severity questionnaire¹¹ which measures the severity of various signs of GAD according to reported response categories with assigned points. Third part contains standardized Patient Health Questionnaire¹² which assess depression of the workers and the final part consists of the Fagerstrom test for Nicotine dependence (Smoking and Smokeless) which is a six-item closed end questionnaire each. The total scores range from 0 to 10 with higher scores indicating high dependence. 0–2 score interprets low dependence; 3–5 score interprets medium dependence; 6–7 score interprets high dependence; >8 score interprets very high dependence⁸ and also the most commonly used questionnaire to estimate nicotine dependence. GAD-7 Anxiety severity consists of 7 questions in 4 point likert scale(Not at all, Several days, More than half of the days, Nearly every day). Scoring pattern will be 0–4 as minimal anxiety; 5–9 as mild anxiety; 10–14 as moderate anxiety and 15–21 as severe anxiety. PHQ-9 consists of 9 questions in same 4 point likert scale and the scoring pattern interpretation will be 1–4 as minimal depression, workers who has 5–9 score will be scored as mild depression category, 10–14 will be under moderate depression, 15–19 will come under moderately severe depression and 20–27 will be assigned to severe depression category.

2.4. Statistical analysis

The frequency and percent of categorical variables were computed to delineate the demographic characteristics of the study participants. Statistical Package for Social Sciences(SPSS) version 23.0 was used to analyze the findings. Normality tests like the Shapiro-Wilks and Kolmogorov-Smirnov test were estimated. Pearson correlation was also done to assess the correlation between Nicotine dependence, GAD-7 and PHQ-9. Statistical tests like chi-square association and One-Way ANOVA (normally distributed) were used for analysis of three group comparisons. The level of statistical significance was predetermined to be p < 0.05. Since statistically significant relationship was found on between group analysis Pots hoc Tukey's test was carried out for Fagestrom nicotine dependence GAD-7 and PHP1-10.

3. Results

The overall sample size was 416 construction male workers from 5 zones of chennai. Subjects were grouped as workers who smoke, workers who use smokeless tobacco and workers who use both regularly. Among 416 male workers 57.9% were illiterate, 38.2% were studied up to middle school and 2.4% of workers have done their high schooling and only 1.4% of workers had completed diploma/degree. Most of the workers were unmarried(64.9%) and 35.1% were married. This study found that more than three-fourth of the study sample (76.2%) of the study participants worked more than 60 h a week and only 7.7% world below 40 h a week. This also can be one of the factors of their anxiety and depression. Regarding nicotine usage 40.9% belong to Group 1 (smoking), 24.5% belong to group 2(Smokeless) and 34.6% of the workers come under group 3(uses both). More than 53.1% of participants have medium tobacco dependence and only 12% of the participants have low tobacco dependence whereas 10.5% of participants have very high tobacco dependence. Most of the workers started using tobacco between 21 and 25 years(43%) and 38.7% of the workers. 16.6% of the participants have minimal anxiety, 28.4% of the workers have mild anxiety and 32.5% of workers have moderate anxiety and 22.5% have severe anxiety. After analyzing the PHQ-9, almost 24.2% have severe depression, 32.4% have moderately severe depression, 28.8% have moderate depression, 8% have mild depression and 6.6% have minimal depression(Table 1).

Table 1.

Demographic details of the study participants.

Sl. No	Variable	N (%)
1	Age <25 years 26–35 years 35–45 years >45 years	32.7 41.6 14.7 10.6
2	Education Illiterate Middle school High school Undergraduate	57.9 38.2 2.4 1.4
3	Marital status Unmarried Married	64.9% 35.1%
4	Working hours <40 h 40–50 h 50–60 h >60 h	7.7 0 16.1 76.2
5	Tobacco usage form Smoking Smokeless Both	40.9 24.5 34.6
6	How old are you when you first started using tobacco? <20 years 21–25 years >25 years	38.7 43 18.3
7	Minimal anxiety Mild anxiety Moderate anxiety Severe anxiety	16.6 28.4 32.5 22.5
8	Minimal depression Mild depression Moderate depression Moderately severe depression Severe depression	6.6 8 28.8 32.4 24.2
9	Very low dependence Medium dependence High dependence Very high dependence	12 53.1 24.3 10.6

A highly statistically significant difference (p = 0.00) was found on finding the association of fagerstrom nicotine dependence with the groups(smokers, smokeless and both users) from One-way ANOVA test. Statistically significant differences were found on comparing GAD-7 and type of tobacco users(p- 0.02) and also PHQ-9 and type of tobacco users(p-0.03) on one-way ANOVA tests (Table 2). Table 3 shows that positive correlation was found between nicotine dependence, GAD-7(r = 0.82 and PHQ-9(r = 0.79)(Table 2).

Table 2.

Results of analysis of variance.

		Mean ± S.D	P value
1	Fagestrom nicotine dependence Smoking Smokeless Both	2.1 ± 0.6 2.5 ± 0.7 2.4 ± 0.9	0.00*
2	GAD-7 Smoking Smokeless Both	1.8 ± 0.9 2.1 ± 1.01 1.7 ± 0.4	0.02*
3	PHQ-9 Smoking Smokeless Both	1.1 ± 0.09 1.21 ± 0.11 1.17 ± 0.09	0.03*

*p < 0.05 – significant.

Table 3.

Correlation between Fagestrom nicotine dependence, GAD-7 and PHQ-9 using Pearson's correlation.

Variables	Pearson's correlation value(r)	P value
Fagestrom nicotine dependence and GAD-7	0.8	0.234
Fagestrom nicotine dependence and PHQ-9	0.6	0.435

On comparing the relationship between working hours with fagerstrom nicotine dependence, GAD-7 and PHQ-9 a highly statistically significant difference was found for all the three cases with p = 0.04, p = 0.05, p = 0.01 respectively. Statistically significant difference was found on assessing the association between fagerstrom nicotine dependence and GAD-7 and PHQ-7 total score(p < 0.05) (Table 3). Table 4 illustrates the association between the variables, which implies statistically significant differnce was found when comparing nicotine dependence with working hours (p=0.04), working hours with PHQ-9 (P=0.01), nicotine dependence with GAD-7 (p=0.03) and nicotine dependence and PHQ-9 (p=0.02). Fig. 1 represents the error bar representing mean GAD-7 among groups based on nicotine users. Fig. 2 represents the error bar representing mean PHQ-9 among groups based on nicotine users. Fig. 3 represents the error bar representing Fagerstrom nicotine dependence among groups based on nicotine users. A statistically insignificant relationship was found on assessing the relationship between duration of nicotine in years and nicotine dependence(p = 0.803). From Table 5 multiple pairwise comparisons were done between groups and Fagestrom nicotine dependence which implies that statistically significant relationship((p-0.000) was found on all comparisons except Both smoking and smokeless users and Smokeless users(0.454)

Table 4.

Association using Chi-square test.

Variables	Chi-square value	P value
Fagestrom nicotine dependence and working hours	6.072	0.04*
Working hours and GAD-7	12.478	0.05*
Working hours and PHQ-9	19.545	0.01*
Fagestrom nicotine dependence and GAD-7	10.108	0.03*
Fagestrom nicotine dependence And PHQ-9	8.727	0.02*
Duration of nicotine in years and nicotine dependence	50.522	0.803

*p < 0.05 – significant.

Fig. 1.

Error bar representing mean GAD-7 among groups based on nicotine users.

Fig. 2.

Error bar representing mean PHQ-9 among groups based on nicotine users.

Fig. 3.

Error bar representing mean Fagerstrom nicotine dependence among groups based on nicotine users.

Table 5.

Multiple pairwise comparisons of Fagestrom nicotine dependence among groups using Post hoc Tukey test.

Groups		Mean Difference (I-J)	Std. Error	Sig.(p value)
Smoking	Smokeless Both	−0.468 −0.344	0.100 0.090	0.000* 0.000*
Smokeless	Smoking Both	0.468 0.124	0.100 0.103	0.000* 0.454
Both	Smoking Smokeless	0.344 −0.124	0.090 0.103	0.000* 0.454

. From Table 5, Table 6, Table 7 results of multiple pairwise comparisons of GAD-7 (p- 0.01) and PHP-10 (p- 0.03) with the study groups, statistically significant relationship was found on Both users and smokeless users.

Table 6.

Multiple pairwise comparisons of GAD-7 among groups using Post hoc Tukey test.

Groups		Mean Difference (I-J)	Std. Error	Sig.(p value)
Smoking	Smokeless Both	−0.249 0.096	0.123 0.111	0.108 0.661
Smokeless	Smoking Both	0.249 0.345	0.123 0.127	0.108 0.01*
Both	Smoking Smokeless	−0.096 −0.345	0.111 0.127	0.661 0.01*

Table 7.

Multiple pairwise comparisons of PHP-9 among groups using Post hoc Tukey test.

Groups		Mean Difference (I-J)	Std. Error	Sig.(p value)
Smoking	Smokeless Both	0.321 0.070	0.148 0.134	0.079 0.859
Smokeless	Smoking Both	0.321 0.392	0.148 0.153	0.079 0.03*
Both	Smoking Smokeless	−0.070 −0.392	0.134 0.153	0.859 0.03*

4. Discussion

This study was unique in assessing the association between long working hours, nicotine dependence, anxiety and depression among construction workers.

The present study showed that most of the study participants were illiterate and only few have completed their high schooling which is contrary to the study done by Tiwary et al.¹³ Most of the participants were unmarried (64.9%) which is in accordance with.¹⁴ Almost 75% of the workers work more than 60 h per week which can also be a cause for increased anxiety and depression among workers nowadays which is similar to the study done in Korea.⁴ According to Brooms et al.,¹⁵ married men showed decreased nicotine dependence as their family members made them reduce their nicotine usage behaviour through care. From our study results, marital status does not have an impact on nicotine behaviour which was similar to Schmidt et al.,¹⁶ he found that marital status does not influence nicotine dependence whereas low education influences like our study. From our study results, nicotine dependence was high for the illiterate people. Moreover nicotine dependence was found more among older people which implies nicotine dependence becomes stronger with age.

People who work for more hours have more anxiety and depression compared with other workers which implies long working hours have a direct impact on workers mental health too which is similar to the author Kouvonen et al.¹⁷ From our study results, most of the workers started their nicotine usage between 21 and 25 years similar to the study conducted by Blay et al.¹⁸ On comparing smokers, smokeless users and users of both with nicotine dependence they exhibit a significant difference.

Workers who have medium and high nicotine dependence exhibit high levels of anxiety and depression which implies that mental health is affected by smoking behaviours.^19,20 Workers have to be on tobacco cessation counselling regularly so that they can reduce the distress. Increased smoking dependence has a variety of causes like growing workplace smoking, anxiety, stress, long working hours and personal issues and physical stress. Steps like ban smoking from the workplace, each company should reduce their workers working hours which can reduce the stress, anxiety and also physical stress.

Limitations

• -Due to the retrospective design of our study, there may be memory-based distortions in the participants' responses
• -Since this was a correlative cross-sectional study, only associations could be examined. Furthermore, surveys can be done with a large sample size.

Future research

• -Both the findings of previous studies as well as the findings of the present study indicate the need for further investigations
• -The FTND was not completely helpful to assess employee dependence during their working hours. Future studies should aim to estimate a more reliable assessment of employee smoking behaviour at work.
• -In future studies it will be interesting to estimate whether there is an association between work stress and nicotine dependence. However, a larger sample size would be needed

Conclusion

Nicotine dependence plays a vital role in an individual's anxiety and depression level. Higher the nicotine dependence higher their anxiety and depression level. Long working hours was found out to be another factor which influences workers mental health. Based on this result, it was clear that workers who have high nicotine dependence should definitely make an attempt to reduce their dependence which can impact their mental health too.