Industrial Psychiatry Journal

ORIGINAL ARTICLE
Year
: 2010  |  Volume : 19  |  Issue : 2  |  Page : 125--129

Predictors and prevalence of nicotine use in females: A village-based community study


Mona Srivastava1, Preeti Parakh2, Manashi Srivastava3,  
1 Department of Psychiatry, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
2 Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh, India
3 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India

Correspondence Address:
Mona Srivastava
36/2 H.I.G Kabir Nagar Colony, Durgakund, Varanasi - 221 005, Uttar Pradesh
India

Abstract

Background: Nicotine use and abuse is gaining increasing attention due to its negative and serious medical consequences. Multiple morbidities occur due to the intake of nicotine in various forms. Aims: To find the prevalence and type of nicotine use/abuse in females. Settings and Design: House to house survey in a village in Purvanchal, i.e. eastern part of Uttar Pradesh and bordering Bihar. Materials and Methods: Semi-structured performa was used to collect data; a house to house visit was made to collect data. Statistical Analysis: Simple percentages were calculated. Results: Tooth powder form of nicotine use is common and the need to address this problem is urgent. Conclusions: Widespread dissemination of knowledge and legislative measures have to be undertaken to stop the problem.



How to cite this article:
Srivastava M, Parakh P, Srivastava M. Predictors and prevalence of nicotine use in females: A village-based community study.Ind Psychiatry J 2010;19:125-129


How to cite this URL:
Srivastava M, Parakh P, Srivastava M. Predictors and prevalence of nicotine use in females: A village-based community study. Ind Psychiatry J [serial online] 2010 [cited 2019 Aug 24 ];19:125-129
Available from: http://www.industrialpsychiatry.org/text.asp?2010/19/2/125/90344


Full Text

Socioeconomic inequality is widely prevalent in India, especially so in urban areas. [1],[2] Socioeconomic disadvantage is inextricably linked to several behaviors that influence health, tobacco being one of them. [3] The rate of smoking is expected to increase by 3% every year, leading to 1 million deaths annually by 2010. [4],[5] After China, India is the second highest consumer of tobacco in the world. [6],[7] Currently, about 230 million males and 11.9 million females consume tobacco in India. [8] Strategies designed to alleviate tobacco use in India are unfruitful because of its consumption in varied forms. [6],[9] Owing to the variety of tobacco products consumed in India, varying health consequences are encountered, e.g. higher rate of oral cancer, [10] increased incidence of tuberculosis (TB), increased incidence of cervical cancer, [11] and complications of pregnancy. [12] Use of all forms of tobacco is associated with higher all-cause mortality in the Indian population. [13] The commonest form in which smokeless tobacco is used is "mishri" or "gul," a black powder obtained by roasting and powdering tobacco, meant to be applied to the gums like a toothpaste. [9] Another common form is chewing of betel quid [13] which is a combination of betel leaf, areca nut, slaked lime, tobacco, and condiments. The smokeless forms of tobacco consumption in India include chewing of tobacco and inhalation of snuff. [14],[15] Chewing tobacco is consumed in the form of gutkha and zarda. [6] Gutkha, a sweetened mixture of tobacco, betel, and catechu, is sold in brightly colored packets; it is commonly used by children and women who chew it and then spit out the remaining portion. [16],[17] Zarda, a dried and colored residual tobacco, is obtained by boiling tobacco leaves with spices and lime. [17] In comparison to men, Indian women are much less likely to smoke tobacco (3.4 vs. 33.3%), chew tobacco (13 vs. 29%), and use tobacco in smoke and smokeless forms (15.5 vs. 50.2%). [16],[18]

Among the tobacco users, bidi smokers constitute 40%, cigarette smokers 20% and those using smokeless forms 40%. [9] The prevalence of tobacco use in 1993-1994 was 23.2% in males (any age) and 4% in females (any age) in urban areas, and 33.6% in males and 8.8% in females in rural areas. [13] The National Family Health Survey [5] had revealed that individuals with no education were 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. This study had also shown that households belonging to the lowest fifth of a standard living index were 2.54 times more likely to consume tobacco than those in the highest fifths. [19] Thus, illiteracy and poverty were associated with tobacco consumption in India. [13]

Although smoking by women is a taboo in the Indian society, [20],[21] consumption of smokeless tobacco is well accepted and use of mishri (tobacco containing teeth cleaning powder) or "gul" is very common. [22],[23] Various studies have estimated the prevalence of the use to be from 17 to 45%. [23] In the state of Uttar Pradesh, the prevalence of tobacco use in females is 9.1%,correction is ok) out of which 7.6% females use the smokeless variety. [9] Females form a vulnerable group due to various factors like illiteracy, poverty, malnutrition, child bearing, multiple pregnancies and social inequality. [24] Awareness regarding the ill effects of tobacco and its exposure to the unborn child is minimal. Most of the females are not aware of the tobacco content of the toothpaste variety, as adequate legislative measures are lacking. [18],[25] The above-mentioned factors increase the magnitude of the problem. There is a paucity of data related to tobacco intake in females from the eastern Uttar Pradesh region. Hence, the present study was undertaken to address this gap in information.

Aim of the study

The study was undertaken with an aim to find the prevalence of nicotine use in the female population of a rural community, the pattern of nicotine use, and the level of awareness regarding nicotine use, and to try and explore the predictors of use of different forms of tobacco in this population. In the present article, the terms tobacco and nicotine will be used interchangeably.

 Materials and Methods



The present study was conducted in Tikari village which is located 10 km away from the university and is a part of the community outreach of Community Medicine Department. All females above 10 years of age were examined on semi-structured Performa which included data about the general socio-demographic features and type, quantity, duration of tobacco use, awareness about the content of the product and its medical complications, and presence of any physical complications in the subject. At the end of the study, all the participants were given active education in group setting, and if needed, individual reference was done to the hospital tobacco cessation and control center (TCC). Participants having other complications were referred to the specified departments of the hospital and were actively monitored on a longitudinal basis regarding their well-being. Before examining the subjects, a written informed consent was taken; in the case of an illiterate participant, consent was taken by informing the individual and taking the thumb impression. The study was approved by the institute ethical committee.

 Results



[Table 1] shows the salient statistical features of Tikari village. The education level of the village is better than the national average; [5] this is mainly due to its close proximity with the town and as a result of the active outreach services. The number of females above 10 years was 3847 (47.3%), and the number using tobacco in any form was 352.23 (9.4%). The use of smokeless form was much higher (80% vs. 20%) [Figure 1] and [Table 2].{Table 1}{Table 2}{Figure 1}

Predominantly tobacco was used in the form of pan (betel leaf with lime catechu and tobacco), khaini (chewable tobacco mixed with lime) and gul (toothpaste form of tobacco) [Figure 2] and [Table 3]. Commonly, multiple forms of tobacco consumption were prevalent in the subjects (60 vs. 40%) [Figure 2] and [Table 4]. About 77% females were unaware of the nature and nicotine content of the product being consumed, this aspect was more apparent in toothpaste and lip balm variety of tobacco use [Figure 3]. The consumption of tobacco showed two peaks between 30-40 years and after 50 years [Figure 4] and [Table 5].{Table 3}{Table 4}{Table 5}{Figure 2}{Figure 3}{Figure 4}

 Discussion



Our study area was a comparatively literate and financially well-to-do village in contrast to the national data. [5] The percentage of females in the village is in keeping with the national average. [5] Our study found about 9% females to be using tobacco; this is same as that reported in other surveys and studies. [26],[27] Most common form of use in females was smokeless variety, out of which the toothpaste form was more popular; this finding was also reported by other studies. [25] The toothpaste form is more dangerous as it is used in an unsuspecting form and commonly by the reproductive age group, thus leading to the likelihood of in utero complications. [24] The easy availability and lack of awareness regarding the product lead to its increased consumption. [28] Most of the knowledge dispersed focuses on the popular forms like gutka, zarda, khaini, [16] and smoked varieties like bidi and cigarette. [29] Predictably, the smoked form was used by fewer females (20%); various other surveys give a similar picture. [16],[30] Our finding assumes importance since the study site was a village which is monitored by the hospital and has a primary health center and a primary school, is connected by a motorable road, has access to government welfare schemes, and is nearer to town. The high use of tobacco by females in this scenario highlights the "unknown" nature of use. [31] Our study found that there are certain predictors of tobacco use in females, e.g. gul, i.e. toothpaste variety, is used by females in the age group of 25-45 years, those belonging to middle- and upper-income group, and those likely to be economically independent; as the usual employment for females is vegetable selling, most often these females suffer from toothache and headache. Use of gul for toothache is a common practice in the villages, leading to the subject becoming an unsuspecting addict who is compelled to take it in order to stop the withdrawal symptoms. [29] In contrast, surti, khaini form of nicotine is used by females of age 40-60 years, belonging to lower-income group, having one male member who is a regular user or a friend who is a nicotine user. These findings are interesting as they have not been reported in any study so far and also because these have a direct implication on the health givers and policy framers. [32],[33] In case of toothpaste variety, emphasis should be on the reproductive health, [25] and the middle-aged women should be examined to rule out any precancerous lesions. [24] To conclude, our findings emphasize the need for a stringent law which is applicable to all forms of nicotine containing products. [34] Unsupervised selling at open shops should be curbed by appropriate measures; statutory warning like the one that cigarette packs carry should be made compulsory on all tobacco containing products. [35] Routine medical examinations should also include a nicotine screening test. [36] The limitation of our study is that we did not try to rate the severity of nicotine dependence, or the medical or mental co-morbidities, as has been seen in other studies. [33],[37] We did not examine the subjects regarding the presence of nicotine-related complications; however, we did active referrals in those subjects where it was indicated. [16] To be helpful in the formulation of a strategy, our study needs to have a larger sample; alternatively, a study of nicotine intake needs to be carried out on the medically and psychiatrically ill females and an attempt to correlate the complications of nicotine intake with the type and amount of nicotine consumption should be attempted.

 Acknowledgment



We are thankful to the Medical Officer in-charge of Tikari village, and would like to thank the villagers for their cooperation.

References

1Mathur C, Stigler MH, Perry CL, Arora M, Reddy KS. Differences in prevalence of tobacco use among Indian urban youth: The role of socioeconomic status. Nicotine Tob Res 2008;10:109-16.
2Worcester N, Whatley MH. Women′s Health: Readings on Social Economic and Political Issues. Kendall/Hunt publishing,Dubuque,IA; 1988.
3Jarvis MJ, Wardle J. Patterning of individual health behaviours: The case of cigarette smoking Social determinants of health. In: Marmot MG, Richard G, editors. Wilkinson: Oxford books; 2006.
4Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R,et al. A nationally representative case-control study of smokingand death in India. N Engl J Med 2008;358:1137-47.
5International Institute for Population Sciences and Macro International. National Family Health Survey-3 (2005-6), IIPS, Mumbai, India, 2007. Available from: http://www.nfhsindia.org/volume_2.html. [Last accessed 2010 Jan 30].
6Gupta PC, Mehta HC. Cohort study of all-cause mortality among tobacco users in Mumbai, India. Bull World Health Organ 2000;78:877-83.
7Gajalakshmi CK, Jha P, Ranson MK, Nguyen SN. Global patterns of smoking and smoking attributable mortality. In: Jha P, Chaloupka F, editors. Tobacco Control in Developing Countries. Oxford: Oxford University Press; 2000. p. 11-39.
8Shafey O, Eriksen M, Ross H, Mackay J. The Tobacco Atlas.(3 rd edition): The American Cancer Society; Atlanta, Georgia, 2009.
9Subramanian SV, Nandy S, Kelly M, Gordon D, Davey Smith G. Patterns and distribution of tobacco consumption in India: Cross sectional multilevel evidence from the 1998-9 national family health survey. BMJ 2004;328:801-6.
10World Health Organization. Tobacco or Health: A global status report, country profiles by region. Geneva: World Health Organization; 1997.
11Vijayan VK, Kumar R. Tobacco cessation in India. Indian J Chest Dis Allied Sci 2005;47:5-8
12World Health Organization. The tobacco epidemic: A crisis of startling dimensions. Geneva: WHO statement for world no-tobacco day; 1998.
13Jha P, Ranson MK, Nguyen SN, Yach D. Estimates of global and regional smoking prevalence in 1995 by age and sex. Am J Public Health 2002;92:1002-6.
14Joshi U, Modi B, Yadav S. Study on prevalence of chewing form of tobacco and existing quitting patterns in urban population of Jamnagar, Gujarat. Indian J Community Med 2010;35:105-8.
15World Health Organization. Report of regional health status. Geneva: WHO; 1998.
16World Health Organization. Tobacco or Health: A Global Status Report. Geneva: World Health Organisation; 1997.
17Gajalakshmi V, Peto R. Smoking, drinking and incident tuberculosis in rural India: Population-based case-control study. Int J Epidemiol 2009;38:1018-25.
18World Health Organisation. World Health Assembly Resolution 56.1, The WHO Framework Convention on Tobacco Control. Tobacco Free Initiative. Geneva: WHO; 2003. Available from: http://www.who.int/tobacco/framework/final_text/en. [Last accessed on 2010 May 1].
19Ministry of Health and Family Welfare. TB India 2007, RNTCP status report. Available from: http://www.tbcindia.org/pdfs/TB%20India%202007.pdf. [Last accessed on 2010 Jan 30].
20Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: Retrospective study of 43000 adult male deaths and 35000 controls. Lancet 2003;362:507-15.
21Pednekar MS, Gupta PC. Prospective study of smoking and tuberculosis in India. Prev Med 2007;44:496-8.
22Gajalakshmi CK, Ravichandran K, Shanta V. Tobacco-related cancers in Madras, India. Eur J Cancer Prev 1996;5:63-8.
23Pratinidhi A, Gandham S, Shrotri A, Patil A, Pardeshi S. Use of ′Mishri′: A smokeless form of tobacco during pregnancy and its Perinatal Outcome. Indian J Community Med 2010;35:14-8.
24Centers for Disease Control and Prevention (CDC). Available from: http://www.cdc.gov/tobacco/global/gyts/factsheets/searo/2006/India_factsheet.htm. [Last accessed on 2011 Jan 22].
25Khare R. Use of Mishri in day to day life of an urban slum community of Managalwar Peth, Pune. PRESM. J Comm Health 1993;18:77-82.(checked the name)
26Gupta PC, Warnakulasuriya S. Global epidemiology of areca nut usage. Addict Biol 2002;7:77-83.
27Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.
28Prevalence and correlates of tobacco use and nicotine dependence among psychiatric patients in India. Addict Behav 2005;30:1290-9.
29Anonymous. Betel quid and areca nut chewing (Review) I ARC monograph. Eval Carcinog Chem Hum 1985;37:137-202.(the reference is cited in this way on the net)
30Pednekar MS, Gupta PC, Shukla HC, Hebert JR. Association between tobacco use and body mass index in urban Indian population: Implications for public health in India. BMC Public Health 2006:6:70.
31Perry CL, Stigler MH, Arora M, Reddy KS. Preventing tobacco use among young people in India: Project MYTRI. Am J Public Health 2009;99:899-906.
32Policy Recommendations for Smoking Cessation and Treatment of Tobacco Dependence: Tools for Public Health. In: Costa e Selva V, editors. Geneva: World Health Organisation; 2003.(The editors are mentioned but no specific author is mentioned)
33The Gazette of India Extraordinary, Part-II. Ministry of Law and Justice (Legislative Department). The Cigarettes and other tobacco products (Prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) Act, 2003. Available from: http://www.mohfw.nic.in/tobacco_control_Act-2003) [Last accessed on 20110 Apr 14].
34Arora M, Tewari A, Tripathy V, Nazar GP, Juneja NS, Ramakrishnan L, Reddy KS. Community - based model for preventing tobacco use among disadvantaged adolescents in urban slums of India Health Promotion International Advance Access published online on Feb., 2010.
35Reddy SS, Shaik HA. Estimation of nicotine content in popular Indian brands of smoking and chewing tobacco products. Indian J Dent Res 2008;19:88-91.
36Shimkhada R, Peabody JW. Tobacco control in India. Bull World Health Organ 2003;81:48-52.
37Saddichha S, Khess CR. Prevalence of tobacco use among young adult males in India: A community-based epidemiological study. Am J Drug Alcohol Abuse 2010;36:73-7.