The Impact of Tobacco Usage & Nicotine Dependence on People's Health

Introduction

Tobacco is the leading cause of premature death and cancer. The use of tobacco and exposure to tobacco smoke have severe negative health, economic, environmental and social consequences, and people should be educated about these negative consequences and the benefits of cessation (Article 12 of the WHO FCTC)1. The prevalence of tobacco usage around 266.8 million, according to Global Adult Tobacco Survey (2016-2017)2 and 28, 64,400 tobacco users in Tamil Nadu-aged 15 years & above use tobacco in any form, which is significantly a higher number (TNTS, 2015)3.. According to GATS, 55.4% (Smoking) and 49.6% (Smokeless) of current users are planning or thinking of quitting tobacco2.

The current users (54%) were concerned about their tobacco use, 17.2% were thinking of quitting in the next one month and 38.9% of the current users had made an effort to quit tobacco in the last 12 months (TNTS, 2015)3.Tobacco/nicotine dependence is a condition that often requires repeated treatments, but there are helpful treatments and resources for quitting. Quitting tobacco greatly reduces the risk of developing tobacco related diseases. Therefore, it is essential to provide tobacco cessation services to the current tobacco user. This present study was carried out to assess the quit status and to find out the challenges in quitting and reasons for not quitting tobacco.

Method

Tobacco cessation clinic (TCC) is being run in the Resource Centre for Tobacco Control (RCTC) and Department of Psycho Oncology, Cancer Institute (WIA), Adyar, Chennai. It is located at the centre of the institute which is easily accessed by the clients. Advertisements like the IEC (Information, Education and Communication) materials were distributed in schools, colleges, communities and displayed advertisement boards in the CI. Trained psychologists are involved in the cessation service. Data was collected retrospectively from the Tobacco Cessation Clinic (TCC) database at the RCTC. A total of 175 tobacco users who reported to the TCC between the months of January to December, 2015 were included in the study.

A structured case record form was used to collect and document the demographic details of the clients like age, sex, education, occupation, marital status, income, living arrangement, reasons for current consultation, past quit attempts and current use among smokers and chewers (smokeless tobacco users). Information on use of other addictive substances (e.g. alcohol) and family history of tobacco usage, presence of medical co-morbidities and psychiatric/ psychological issues were also collected. All the clients were assessed using Fagerstrom Test for Nicotine Dependence for their addiction level (Fagerstrom KO’1990)7 and Readiness to Quit Tobacco Scale to assess their stages of change (Karthick Lakshmanan and Dr.E.Vidhubala 2012, unpublished scale)8.

All clients were interviewed and categorized into one of five ‘stages of readiness to change’:

• Pre-contemplation stage: not interested in change;
•  Contemplation stage: awareness that tobacco is a problem but still attached to the behavior or continually thinking about change.
• Preparation stage: planning to take action very soon;
•  Action stage: visibly make changes and put considerable effort into it.
• Maintenance stage: successful changers move systematically through all the stages (Prochaska and Di Clemente)

Behavioral Interventions offered to all the tobacco users. Tobacco related IEC material was given for all the clients. All clients are counseled to re-visit the clinic depending on their addiction level on a regular basis. In addition; clients were also advised to attend Tobacco Free Association (TFA) support group meetings at RCTC, Cancer Institute (WIA). All the clients who were present for the support group meeting were screened for oral cancers. The clients included for this study were contacted through telephone during June 2016. All clients interviewed telephonically were done to assess their quit status and challenges faced by the clients using author constructed questions.

Statistical analysis

The data was analyzed for tobacco user’s characteristics using Chi-square test and the Student’s t-test. Statistical analysis was performed using IBM SPSS Statistics 20 for Windows and p<0.05 was considered to be statistically significant.

Results

Characteristics Frequency (%)

Age in years

17-24 21 (12%)

25-44 94 (55%)

45-75 56 (32.7%)

Residence

Rural 128 (74.9%)

Urban 39 (22.8%)

Missing 4 (2.3%)

Education

No Formal schooling 5 (2.9%)

Primary 25 (14.3%)

Secondary 43 (24.6%)

Graduation and above 95 (54.3%)

Missing 3 (1.8%)

Occupation

Student 8 (4.7%)

Self Employed 49

Retired 6 (3.5)

Salaried 100 (58.5%)

Unemployed 5 (2.9%)

Missing 2 (1.2%)

Marital status

Unmarried 55 (32.2%)

Married 114 (66.7%)

Missing 2 (1.2%)

Type of family

Nuclear 167(97.7%)

Joint Family 2 (1.2%)

Missing 2 (1.2%)

Religion

Hindu 150 (87.7%)

Christian 12 (7%)

Muslim 7 (4.1%)

Missing 2 (1.2)

Type of tobacco used

Smoking 101 (59.1%)

Smokeless 31 (18.1%)

Both 39 (22.8%)

Of the 175 tobacco users only 4 women reported to TCC so they are not included for the analysis. About 35.7% of the tobacco users were referred from various departments of the Cancer Institute, 11.1% were referred from outside the hospital and 28.1% were ‘walk-in’ clients attempting to quit tobacco on their own, 16.4% motivated either by posters and banners displayed or by others tobacco cessation clients. Most of the clients were in the middle income group 48%.

Majority of the participants in the study initiated tobacco usage as a result of influence by peers 66.1% while 22.2% reported curiosity and interest as the reasons for initiating and 11.7% started because of physical or psychological reasons. It is also seen that majority of the clients 56.7% were intrinsically motivated and approached the clinic, whereas only 13.5% were motivated by others, 16.4% were concerned about health,8.2% were using tobacco during the treatment and 5.3% were came from checkup. Majority of the clients 65.9% reported habit as a factor for maintaining their tobacco usage and 13.2% and 7.7% reported pleasure and social reasons, respectively.

From the baseline assessment, it was observed that majority of the clients in the study were found to have very low dependence (27.5%), had medium (22.2%), high dependence (22.2%) and very high dependence (9.4%) The stages of motivational assessment revealed that 32.2% of the tobacco users were in the pre contemplation stage, 43.9% were in the contemplation stage, 14.6% in the preparation stage, 7% in the action stage, 1.2% were in the maintenance.