Category: Tobacco Use

The Relationship between Socio-Economic and Environmental Factors and Smoking among Teens and Adults in New Hampshire

Abstract

The paper seeks to review the relationship between socio-economic and environmental factors with smoking among teens and adults in New Hampshire. The paper is developed from a qualitative research process that involved an extensive review of the literature regarding smoking and factors that influence the decision to begin smoking or continue smoking despite numerous information regarding the health consequences of health smoking. The study established that social-economic and environmental factors do indeed influence smoking behavior because they determine the acceptable behavior and norms within society.

Introduction

Tobacco smoking is a major challenge in many societies. In fact, Tobacco smoking is not a leading cause of both premature and preventable deaths in the world but a serious concern with regard to individuals, environmental health, and wellbeing. In addition to the health problems that result from cigarette smoking, governments and individuals spent numerous resources to deal with both the direct and indirect effects of cigarette smoking despite losing many productive hours. Numerous attempts have been initiated to help curb or reduce the rates of cigarette smoking including numerous studies, documentation, and advertisements showing and making the consequences to health both immediate and long-term of cigarette smoking well known.

Despite these efforts at educating, preventing, and curbing cigarette smoking, millions of people continue smoking, while many others also begin smoking raising the question regarding the influences and motivations that would drive someone to continue smoking or begin smoking despite knowing the risks to their health.

With foregoing in mind, the purpose of this paper is to add to the existing body of literature regarding the factors ( biological, psychological, social-economic, and environmental) that influence tobacco consumption with a specific focus of exploring whether, social-economic and environmental factors have an influence on the consumption and dependence of Tobacco among adults and adolescents in New Hampshire, USA. Further, the study provides actionable recommendations based on the identified evidence that can help reduce, control, and prevent tobacco use and dependence among adolescents and adults in New Hampshire.

Methodology

The study was conducted using a qualitative research method that involves an exploration and extensive review of existing literature from studies and articles focused on examining associations between smoking with socio-economic and environmental variables. All studies selected for the purpose of the literature review had to be directly related to smoking and had been published not earlier than the year 2010.

Literature Review

Background

Tobacco smoking is a major public health issue and challenge to many countries globally. This is despite the fact that cigarette or tobacco smoking is responsible for the highest cases of preventable diseases and deaths in the world (Johnson. et.al. 2018). Moreover, smoking poses huge burdens to both individuals’ countries and the environment. In the United States alone and according to the Centers for Disease Control and Prevention (CDC), more than 18.1% of the United States population are regular smokers, with 2,100 of these people, both adolescents and adults being daily smokers (Jamal et al., 2015). Moreover, Marshal. et.al, (2016) posits that smoking causes 480,000 deaths annually representing 1 in every 5 deaths recorded in the country.

In the state of New Hampshire, which forms the basis for this study, Tobacco use and dependence rank high according to the state’s health improvement plan 2013-2020. This is because smoking and associated health problems are not only the major killer in the state but also because the state incurs numerous economic losses resulting from tobacco use and its associated effects. For instance, Tobacco smoking causes more than 1,764 deaths in the state each year (Johnson. et.al. 2018).

Moreover, the state runs into billions of economic expenses and consequences due to smoking. Despite the staggering consequences of smoking and attempts at preventing and controlling the use of tobacco, the state is among the highest ranking in terms of tobacco use with 19.5% regular smokers and over 1,700 adolescents becoming new smokers every year. The state, therefore, has a plan to not only reduce cigarette smoking among adults and adolescents but also prevent the number of new initiations by 2020.

The case of New Hampshire is therefore crucial to this study as it provides a basis for examining the factors, especially social-economic and environmental factors, and their relationship with cigarette smoking given that many people are still smoking and getting initiated into cigarette smoking despite numerous efforts to prevent or reduce smoking and huge costs associated with smoking. This is even more important to understand the influences among adolescent smokers given that over 80% of adult smokers began smoking during their adolescent or young adult ages (Mennis, Stahler & Mason, 2016). To achieve this, there is a need to understand the factors that influence smoking in order to establish preventive or advocacy measures.

Socio-Economic Status and Environmental Factors

Cigarette smoking or tobacco use in teens and even adults is determined by risk factors which may be biological social-economic or environmental, which either present themselves as protective or risks in terms of initiation or continued use of cigarettes US Department of Health and Human Services. (2012). While the protective factors reduce the likelihood that an individual will be initiated or continue smoking, the risk factors raise the probability or likelihood of being initiated or starting to smoke and continuing previous smoking behavior.

The personal or biological factors that influence an individual’s likelihood or probability to either become a smoker or not include personal attributes such as impulsivity and rationality among others all associated with the construct of a person and individually unique (Trinidad, et. al. 2017). On the other hand, the social-economic and environmental factors arise from the society or environment that an individual lives in.

Human beings are inherently connected to other human beings; live in an interconnected society characterized by differences in age, ethnicities, race, religion, and class all of which determine their attitudes, beliefs, roles, and consequently behavior (Soneji, Sargent, Tanski & Primack, 2015). Within society, individuals are influenced by the practices that are considered appropriate or inappropriate depending on the society that they find themselves in. Social-economic and environmental factors can be defined as the attributes due to the society that determines the behavior of individuals within a particular society or environment. These factors are defined individually and separately as follows.

Social-economic factors: Social-economic factors explain an individual societal construct as well as their economic situation or position in a given society. They include age, gender, beliefs, culture, religion, ethnicity, class, race, employment, poverty, education, and parenting among others (Evans, Horn & Gray, (2015).

Environmental Factors: Environmental factors are factors due to the society or within a society that promotes or prevents the occurrence of certain behavior and in this case the use of tobacco or cigarette smoking. These factors include regulations, policies, and laws regarding tobacco use, ease of access to cigarettes, and interpersonal variables such as peer pressure.

Social-economic and environmental factors determine societal norms and behavior. Concerning cigarette smoking, these factors determine, when, where, who, and whether cigarette smoking is acceptable or not. For instance, according to Surgeon General’s report in 2012, there has been a reduction in smoking rates in the United States. For instance, in 1964, 50% of the adult male population in America were smokers; both women and children were smoking in large numbers because smoking was highly accepted in all parts of the country.

Moreover, there was increased advisements for cigarettes in the media and the fact that cigarette smoking was tied or associated to higher social class, sexual appeal, and glamour compared to the current period where only 18.7 percent of Americans regularly smoke due to increased awareness, improved living standards, tobacco controls, and education. US Department of Health and Human Services. (2012).

Further, cigarette advisements alone, which is an environmental factor is a key factor in initiations to cigarette smoking or the continued use of cigarettes. This because advertisements not only influence the perception or attitudes of individuals toward cigarette smoking but also increases their urge and influence their intention to smoke (Trinidad, et. al. 2017).

Another social factor that influences initiation into cigarette smoking is religion. This is because some religions such as Hinduism and Christianity while acknowledging the ills of cigarette smoking do not specifically forbid or restrict people from smoking, unlike the Muslim religion. In a case like this, people believing or belonging to Islam as their religion are faced with protective societal factors with regard to initiation to cigarette smoking (Ulrich John, 2019).

Moreover, there is a growing and increasing body of evidence indicating that social and organizational characteristics, especially in neighborhoods that are considered disadvantaged pose a higher likelihood of smoking above the national average when compared with other neighborhoods that fare better both social-economically and politically. For instance, disadvantaged societies have higher poverty levels or low standards of living due to low unemployment and poor pay (Hodder, Freund, Bowman, Wolfenden, Gillham, Dray & Wiggers, 2016). This can translate into broken families and increased emotional distress forcing people within such a society to turn into cigarette smoking as a way of finding some solace or a coping mechanism.

In addition, the literature review showed consistency in the relationship between the likelihood of smoking and lower social-economic status. For example, disadvantaged communities, with lower social-economic status and reduced societal capital experienced higher levels of smoking (Soneji, Sargent, Tanski & Primack, 2015). In determining this, the study particularly focuses on the income of the people within the society as well as the amounts available to adolescents for daily expenditures while in school. However, while examining the role of social capital in relation to increased smoking risk, Evans, Horn & Gray, (2015) found that communities or societies with high social capital or in other words increased parental involvement were less involved in smoking both among the teens and among the adults.

Discussion

A majority of the studies and articles reviewed associated initiation into cigarette smoking and continued smoking to societal and environmental factors. These factors include family structure, ethnicity, unemployment, poverty, religion emotional distress among others. This is because these factors largely determine what society expects or in other words, what the society considered positive and acceptable behavior and by whom (Trinidad, et. al. 2017). For instance, societies that consider smoking acceptable are likely to have more smokers considered to societies where smoking is frowned upon and considered unhealthy or disturbing. These factors, therefore, pose threats or opportunities to individuals with regard to indulgence in tobacco use, and can either, be risks or protective depending on the nature of the social-economic and environmental situations because individuals live in a web of connectivity with other people and their environment.

From the data collected through the literature review, it was established that social economic, and environmental factors influence whether or not an individual will get initiated into cigarette smoking or will continue smoking (Marshall, Lotfipour & Chakravarthy, 2016). The factors found to be responsible for increased initiation and continued cigarette smoking include low social-economic status, increased societal acceptance, and ease of access to cigarettes, peer pressure or the search for approval, inadequate parenting and parental support, low academic levels, and low personal esteem and image (Evans, Horn & Gray, 2015).

Based on this it is imperative that the risk and preventive factors smoking are identified and understood not just merely by their presence but also by their design before any initiative is established aimed at addressing the problem of cigarette smoking in New Hampshire. This is because a preventive factor, for instance, may exist due to a low-level risk factor and not the complete absence of a risk factor (Marshall, Lotfipour & Chakravarthy, 2016).

Theoretical Considerations

According to the literature review, many studies regarding tobacco use among both teens and adults have a theoretical basis or ground upon which they are developed. The theories identified are the social learning theory, the rational approach, and the developmental approach.

Social learning theory: The theory posits that individuals learn, observe, and imitate the behavior of other people in society. For example and as seen earlier, it is more likely for an individual to begin smoking if their society has favorable attitudes towards cigarette smoking or is they see their role models within the society smoke.

Rational Approach: According to the rational approach, individuals are able to make the decision on whether to smoke or not based on their personal attributes and knowledge regarding the benefits and disadvantages of smoking (Trinidad, et. al. 2017). However since the society and environment influence what is considered acceptable societal behavior, an individual may be exposed highly to the risk of cigarette smoking hence becoming a smoker.

Developmental Approach: The approach shows that people are able to learn new ways or behaviors and even change their behaviors as they age. For example, in adolescents, people may easily be influenced by smoking since they are in a period of continuous trial and progression into adulthood.

However as seen from the research, the majority of people who start smoking in their adolescent ages continue smoking in adulthood compared to those that start smoking in the later years of adulthood (Hodder, Freund, Bowman, Wolfenden, Gillham, Dray & Wiggers, 2016). This approach, however, is unable to explain why with regard to social economic, and environmental factors some of the smokers from adult age continue smoking during their ages as adults. Even though these approaches while theoretical have the backing of real-life experiences as seen from the literature review and are sound in explaining the decision to start or continue smoking, none can be comprehensively be used to explain the problem individually and independently.

Conclusion

As seen from the discussion, social-economic and environmental factors influence the use of tobacco either, during initiation to tobacco use or continued consumption of tobacco. Some of the social-economic and environmental factors associated with cigarette smoking include unemployment, poverty, advertisements, inadequate family involvement, religion, and class among others.

In addition, these social factors pose risks and opportunities to either smoke or protection against smoking. With this understanding, it is crucial or imperative that people responsible for either helping societies to curb, prevent or control smoking to understand both the role of the biological and individual factors that promote smoking as well as the social-economic and environmental factors that promote or encourage people into cigarette smoking.

References

1. Jamal, A., Homa, D. M., O’Connor, E., Babb, S. D., Caraballo, R. S., Singh, T. & King, B. A. (2015). Current cigarette smoking among adults—the United States, 2005–2014. Morbidity and mortality weekly report, 64(44), 1233-1240. Retrieved from: https://www.dhhs.nh.gov/dphs/tobacco/ [dhhs.nh.gov]
2. Marshall, J. R., Lotfipour, S., & Chakravarthy, B. (2016).Growing Trend of Alternative Tobacco Use among the Nation’s Youth: A New Generation of Addicts. Western Journal of Emergency Medicine, 17(2), 139.
3. Ulrich John, C. M.-J. (2019). Strength of the Relationship between Tobacco Smoking, Nicotine Dependence and the Severity of Alcohol Dependence Syndrome Criteria in a Population-Based Sample. Retrieved 09 10, 2019, from Alcohol and Alcoholism, Volume 38, Issue 6, November 2003, Pages 606–612: https://doi.org/10.1093/alcalc/agg122 [doi.org]
4. US Department of Health and Human Services. (2012). Preventing tobacco use among youth and young adults. A report of the Surgeon General, 2012.
5. Johnson, A. L., Collins, L. K., Villanti, A. C., Pearson, J. L., & Niaura, R. S. (2018). Patterns of nicotine and tobacco product use in youth and young adults in the United States, 2011–2015. Nicotine and Tobacco Research, 20(suppl_1), S48-S54.
6. Trinidad, D. R., Pierce, J. P., Sargent, J. D., White, M. M., Strong, D. R., Portnoy, D. B. & Shi, Y. (2017). Susceptibility to tobacco product use among youth in wave 1 of the Population Assessment of tobacco and health (PATH) study. Preventive medicine, 101, 8-14.
7. Mennis, J., Stahler, G. J., & Mason, M. J. (2016). Risky substance use environments and addiction: a new frontier for environmental justice research. International journal of environmental research and public health, 13(6), 607.
8. Evans, W. D., Horn, K. A., & Gray, T. (2015). A systematic review to inform dual tobacco use prevention. Pediatric Clinics, 62(5), 1159-1172.
9. Soneji, S., Sargent, J. D., Tanski, S. E., & Primack, B. A. (2015). Associations between initial water pipe tobacco smoking and snus use and subsequent cigarette smoking: results from a longitudinal study of US adolescents and young adults. JAMA pediatrics, 169(2), 129-136.
10. Hodder, R. K., Freund, M., Bowman, J., Wolfenden, L., Gillham, K., Dray, J., & Wiggers, J. (2016). Association between adolescent tobacco, alcohol, and illicit drug use and individual and environmental resilience protective factors. BMJ Open, 6(11), e012688.

“How many more people would have lived longer, productive, happy lives if only we had been able to reduce nicotine use in society sooner.” (Brick et. Erickson, 2013, p. 95)

While taking this course, I have been able to understand the use of medications in the treatment of alcohol and drug dependence. New medications are being used for “less potential for addiction”, while the impact is detrimental by having a direct impact on the neurochemistry of addiction. I have reviewed clinical models of interventions and differential diagnosis while acknowledging how neuroanatomy and neurophysiology will determine insight for medications such as psychotropics, antipsychotics, antidepressants, etc. The focus of this paper will be a medication-assisted treatment for specifically Nicotine.

Nicotine is a chemical that is produced synthetically. According to the Academy of Addiction Psychiatry, approximately 60% to 80% of current smokers fulfill classic criteria for drug dependence; they have difficulty stopping, withdrawal is tolerant, and continue despite knowledge of personal harm. Tobacco use is the most preventable cause of death in the United States. “Smoking causes more than 443,000 premature deaths annually among U.S. smokers alone. In addition, over 49,000 deaths per year among U.S. nonsmokers are associated with environmental tobacco smoke exposure.”(Academy of Addiction Psychiatry, 2018) When discussing nicotine one must also discuss the benefits and risks associated. There should be a changing worldview and openness to new ways Tobacco use can be dealt with it will contribute to how one must provide medications and treatment options.

According to Brick, J., Erickson, C. K. (2013), Nicotine is absorbed from the respiratory tract, membranes in the mouth, and skin. There has been incidences in which severe poisoning has occurred due to accidental contact with nicotine on the skin. This in fact shows how strong this substance is. “An average cigarette has 9 milligrams of nicotine and 12 percent goes into the bloodstream”. (Center of Disease Control, 2019) That is a substantial amount in as little as 20 seconds. Smokeless tobacco, also known as ( chaw or chew) has 5 milligrams of nicotine and it has a slower time before entering the bloodstream. The blood levels are similar due to the slow absorption. Cigars are different in a sense, they do not require inhalation, but rather smoke to be kept in the mouth. Most people tend to hold an unlit cigar in their mouth. If kept in the mouth for too long more nicotine will be absorbed, then someone who holds a cigar in their hand.

Elimination of Nicotine consists of a process of metabolizing in the body, specifically the liver and kidney. This process is about 40 minutes. (Brick, J., Erickson, C. K., 2013) About 5 percent of nicotine is excreted in the urine. The acute fatal dose of nicotine for an adult is 40-60 milligrams of pure nicotine. Within on cigarette 0.2 -2.4 survive even after combustion. Toxicity has been seen in tobacco harvesters as a result of the absorption of nicotine through the skin. (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health 2014)Nicotine can also be excreted in the milk of lactating women, which is why smoking is never advised for pregnant women as results can range from preterm birth to low birth weight. According to Brick, J., Erickson, C. K. (2013), many of the consequences may be due to a decrease in the supply of oxygen to the fetus.

According to the Academy of Addiction Psychiatry, The prevalence of Tobacco use disorders is seen in persons with alcohol and other drug use disorders (e.g., over 80% of alcoholics are current smokers). Evidence in literature indicates treating tobacco does not worsen other treatment outcomes. “Over half of the persons with alcohol/drug use disorders want help to stop smoking but do not receive such help.” (Academy of Addiction Psychiatry) According to The United States National Library of Medicine, men who use any kind of tobacco in urban areas to be 39.2 %. “The prevalence of parental smoking was 42.2% in tobacco users. There were 74.4% smokers reported who were influenced by peers for their initiation into tobacco use.” ( Fast Facts, 2019) The prevalence of tobacco use among the sample of male industrial workers were comparable to the general population.

A significant number of males in young age group are being initiated into the habit by peer influences and later becoming dependent on nicotine. (National Institute for Clinical Excellence, 2002) Restrictions on the use of tobacco products in work sites, Awareness programs on the harmful effects of tobacco, and the options available for treatment of Nicotine dependence are required to be implemented. Although with the vast majority of programs on the harmful effects of tobacco there are some ideas, such as tobacco use disorder is better left untreated. This lacks empirical support and evidence.

Nicotine causes withdrawal symptoms in many people who choose to stop. Most people can stop smoking once they make a decision to stop. People may choose to stop cold turkey ( stopping with no tapering of nicotine dose). Chemical dependence is seen within this particular substance due to the extreme difficulty in trying to stop. (Brick, J., & Erickson, C. K.2013) There is substantial scientific evidence that smoking cessation helps recovery. Research has shown that tobacco cessation does not disrupt alcohol abstinence and can increase longer-term recovery from alcohol and other drugs. (Nicotine Replacement Therapy for Quitting Tobacco) Several forms of smoking cessation include Nicoderm which is a skin patch, nicotine inhaler, and nasal sprays.

The skin patch is placed directly over the skin. It releases a low and steady amount of nicotine over time. Side effects include redness on skin, racing heartbeat, muscle pain or problems sleeping. A nicotine inhaler is a plastic mouthpiece with a replaceable nicotine cartridge inside, which is sucked on like a cigarette. Nasal sprays require a prescription. The medicine reduces cravings to smoke when a measured dose of nicotine solution is sprayed into the nose. The spray is absorbed into the bloodstream through the nasal mucous membrane. For smokeless tobacco users, certain types of NRT(Nicotine Replacement Therapy) may help more than others. If you look at the way the tobacco is used, nicotine gum and lozenges are most like using smokeless tobacco. They also let you control your dose to help keep nicotine cravings down. NRT products roughly match the amount of nicotine you typically took in through tobacco. It can be more of a challenge to get the dose right for smokeless tobacco users since NRT products are labeled for smokers. Those who use 2 to 3 cans or pouches per week would usually try the moderate doses. Those who use less than 2 would start with the lowest doses of NRT. Studies show that all forms of nicotine replacement therapy can help you quit smoking for good, and can more than double your chance of success. How helpful it depends on how much additional support you get around quilting. (Nicotine Replacement Therapy for Quitting Tobacco)

There is a medication called bupropion, which can be used as a cessation program. It is an antidepressant and reduces depression. (Brick, J., & Erickson, C. K.,2013). A new innovation in clinical studies includes a nicotine vaccination. This vaccine is able to block the drug from entering the brain. Nicotine replacement therapies also known as NRT are not as effective in reducing smoking alone. Ongoing counseling sessions to help the smoker stop is required. NRTs are useful in reducing the symptoms of withdrawals. Withdrawal symptoms include intense craving for nicotine, anxiety, weight gain, and depression. (Nicotine Replacement Therapy for Quitting Tobacco, 2018 )Symptoms of tobacco/nicotine withdrawal can be confused with or exacerbate alcohol withdrawal and caffeine intoxication; i.e., both produce irritability, restlessness, anxiety, depression. Caffeine metabolism is affected by tobacco smoking. Although with this substantial amount of means of helping an individual the best advice to give someone. (Nicotine Replacement Therapy for Quitting Tobacco, 2018 )Many pharmacologists believes that nicotine can produce serious effects on the heart even after one has gone through receiving help. Sadly the consequences of nicotine and tobacco use is severe.

There are a few cases of nicotine-induced deaths. Cigarette smoking is responsible for more than 480,000 deaths per year in the United States. According to the CDC, more than 41,000 deaths result from secondhand smoke exposure. This is about one in five deaths annually, or 1,300 deaths every day. Smoking causes cancer, heart disease, and stroke, which includes chronic bronchitis. For every person who dies because of smoking, at least 30 people live with a serious smoking-related illness.

According to Brick et Erickson, postmortem blood concentrations of 11-63 mg/l were seen in five adult subjects who swallowed 20-25 grams of nicotine sulfate solution. In 1967, nicotine was a major drug used in suicides in Hungary. On average, smokers die 10 years earlier than nonsmokers. (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2014)Smoking continues at the current rate among U.S. youth, 5.6 million of today’s Americans younger than 18 years of age are expected to die prematurely from a smoking-related illness. (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2014)This represents about one in every 13 Americans aged 17 years or younger who are alive today. In the United States the percentage of adults aged 18 or older who are current smokers nearly 15 of every 100 non-Hispanic Blacks (14.9%), about 15 of every 100 non-Hispanic whites (15.2%), and about 21 of every 100 people with mixed-race heritage (non-Hispanic) (20.6%). (National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health, 2014)This information indicates forensic considerations that should be acknowledged when speaking about this substance.

Studies of smokeless tobacco products provide some insight into the potential harms of this substance. These products provide a nicotine dose similar to that from cigarette smoking, but without the combustion. There is evidence that some smokeless tobacco products may pose less cardiovascular risk than cigarette smoking. According to The CDC, In particular, snus (Swedish moist snuff) has garnered attention as a potential harm reduction product because of its lower concentration of tobacco-specific nitrosamines and other contaminants and because of ecological observations regarding the trends in tobacco-related diseases in Sweden. ( Tobacco Use Disorder, 2017 ) NRT can help relieve some of the physical withdrawal symptoms so that you can focus on the psychological (emotional) aspects of quitting. Many studies have shown using NRT can nearly double the chances of quitting smoking. It hasn’t been studied as much for quitting smokeless tobacco, but the NRT lozenges may help.(National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. 2014) All forms of NRT is effective and having an understanding to which suits each lifestyle may help with the process of therapy. Tobacco may be the leading cause of preventable death in the United States but with the right resources and treatment, the mortality rate will be lowered.

Works cited

1. Brick, J., & Erickson, C. K. (2013). Drugs, the brain, and behavior: the pharmacology of abuse and dependence. S.l.: Routledge Member Of The T.
2. Fast Facts. (2019, February 6). Retrieved from https://www.cdc.gov/tobacco/data_statistics/fact_sheets/fast_facts/index.htm.
3. National Center for Chronic Disease Prevention and Health Promotion (US) Office on Smoking and Health. (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24455788.
4. National Institute for Clinical Excellence. (2002). Guidance on the use of nicotine replacement therapy (NRT) and bupropion for smoking cessation. London.
5. Nicotine Replacement Therapy for Quitting Tobacco. (n.d.). Retrieved from https://www.cancer.org/healthy/stay-away-from-tobacco/guide-quitting-smoking/nicotine-replacement-therapy.html.
6. Tobacco Use Disorder DSM-5 305.1 (Z72.0) (F17.200). (n.d.). Retrieved from https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200).

Abstract:

Introduction

The research has been introduced on the selected research area which depicts about prevalence of chewing tobacco in the district of Vadodara, Gujarat. Here identification of the research are maintained from different literature sources. Alongside, the research will appropriately follow the method of Questionnaire and cross-sectional survey. Thus, primary data will be collected based on certain demographic trends associated with the rural population of Vadodara, Gujarat, India. Among such trends, special emphasis will remain on factors like age, educational background, job types, and reason of preference for chewing tobacco.

Background

Tobacco chewing has become a great public health issue globally. According to World Health Organization (WHO) report 2002, around one-third of the total population of the world is addicted to tobacco. Around 1.2 million (WHO, 2002) tobacco users live in low and middle-income countries. Tobacco use have contributed to around half of the deaths in developing countries. Tobacco use is one of the most common and preventable causes of oral diseases (WHO report, 2002). No studies have been conducted reporting the prevalence of tobacco chewing in Vadodara district of Gujarat, India.

Aim:

To evaluate the prevalence of tobacco chewing in rural areas of Vadodara district of Gujarat, India.

Question:

What is the prevalence of chewing tobacco among rural population of vadodara, gujarat, india: a cross-sectional survey

Method:

A cross-sectional survey using questionnaire

Data collection:

Data will be collected using geographical variation and age, gender, education, occupation, marital status and cause of tobacco chewing habit will be taken into consideration.

Keywords:

Tobacco chewing, tobacco, smokeless tobacco, prevalence, Vadodara.

Significance:

This survey will help to evaluate the prevalence of tobacco chewing in rural areas of Vadodara district of Gujarat, India.

Background:

From time to time, India has always managed to re-establish its position as the global leader in the domain of tobacco control. Also, use of tobacco has been the foremost among the preventable reason of death as well as disease in India (Iacobelli et al., 2019). Based on the results from the survey conducted by Global Adult Tobacco Society (GATS), more than 326 million of Indians are known for using chewing tobacco or smokeless tobacco. Hence, the resultant burden of despondence as well as morality, as a result of the consumption of this smokeless tobacco is comparatively very high in the Indian subcontinent (Barik et al., 2016). Therefore, the primary purpose of this research is to outline the certain specific patterns of chewing tobacco use as well as the information associated with its health effects in Vadodara district of Gujarat, which is primarily considered a rural area.

Significance of the research

As mentioned before, from the already available evidence it can clearly be suggested that the percentage of oral cancer in India is highest compared to other parts of the world and the sole reason for this is the use of chewing tobacco and its growing popularity among the rural population of India (Kahar et al., 2016). In light of this context, this research study will emphasize on the use of chewing tobacco in the rural region of Vadodara, Gujarat, India. In doing so, the research study will critically analyze the demographic trends which influence the preference of chewing tobacco in that area. Hence, it is evident that the challenge associated with the use of chewing tobacco in the rural parts of India, especially Vadodara is formidable. In light of this fact, the complexity associated with the disadvantaged people who reside in these rural areas of Vadodara must also be considered. Hence, in conducting the research study, the important thing is to consider all the social determinants and furthermore to curb the usage of chewing tobacco on a broader scale (Sidhu et al., 2018). Hence, the monograph based on chewing tobacco in light of the public health of Vadodara will help in bridging a significant gap in the domain of public health. In this regard, it is also important to comprehend that this research study will also offer an overall insight on the influence of chewing tobacco consumption in rural India, in context of Vadodara.

Research aims and Objectives:

AIM: To estimate the prevalence of chewing tobacco in Vadodara district of Gujarat, India.

Thus following the aim the research will be progressed through setting different objectives that are as follows:

1. To identify, why the youth in rural India is falling prey to chewing tobacco.
2. To identify certain demographic trends that lead to chewing tobacco in Vadodara.
3. To increase public awareness on the certain consequences of chewing tobacco.

Research Question:

What is the prevalence of chewing tobacco among rural population of Vadodara, Gujarat, India: A cross-sectional survey.

Literature review:

The literature review has been made using As the objectives for this research study are outlined, and it primarily deals with the consumption of chewing tobacco in rural India, there are strong evidence as to how the growing popularity of this smokeless tobacco or the chewing tobacco, given its lower price range is actually hampering the public health of the rural parts of Vadodara, Gujarat. In this regard, as stated by (Kostova and Dave, 2015) the foremost as well as the most significant objective of this research study is to enhance as well as raise public awareness on the certain consequences of chewing tobacco consumption. Firstly, tobacco is known for containing more than 4000 of different chemical substances, and among these 50 are deadly carcinogens. Consumption of these carcinogens is in turn responsible for 90% of lung cancer, 75% (Kostova and Dave, 2015) of certain chronic emphysema and bronchitis, as well as for 25% (Kostova and Dave, 2015) of chronic ischaemic heart diseases. Hence, government health surveys suggest that on a yearly basis, thousands of deaths are caused by the consumption of these carcinogens in the rural parts of India. The source being the aspects of chewing tobacco in majority of these cases, intruded the factors relating to the research area. Also, according to Varshitha, (2015) the burden of economy, as a result of the tobacco consumption on the poor families in the rural parts of Vadodara cannot be overlooked in this regard. Other than spending on health, food, and other necessities, the priority is becoming addiction to this chewing tobacco. Hence, as stated by (Thakurand Paika, 2018), considering the above-mentioned implications, it is evident that information is the key factor which will facilitate the confrontation of this epidemic usage of chewing tobacco or smokeless tobacco in the rural parts of India; in this context Vadodara. Therefore, from the research study and its findings, the way to address the most significant objective is to raise awareness. It is necessary to make the rural population of Vadodara aware of the ill effects of chewing tobacco. Hence, information is a key tool which will serve the purpose of influencing the policies associated with regulations regarding anti-tobacco.

Furthermore, addressing the certain demographic trend which influences the rural population of Vadodara in using chewing tobacco, certain factors were taken into consideration throughout the course of the research study. The findings were astonishing as they suggested that majority of these people are workers and laborers and they claimed that chewing tobacco gives them the physical strength to perform or tend to their respective duties. However, in reality, it is nothing but fiction. Chewing tobacco is a powerful stimulant which gives the subject a sense of raw energy for a momentary basis. However, the effects wear off quickly, and the person again uses the tobacco in order to feel the sense of satisfaction he gets (Kahar P, 2016). This kind of behavior leads to addiction and constant use. Furthermore, considering the aspect of advertising, it is mentioned worthy that the way tobacco companies project a sense of style and lifestyle, as well as fashion sense among the youth and as a sign of male authority, that it captivates majority of the youth (Mishra S, 2013) in the rural areas of Vadodara and they also fall prey to the consumption of this smokeless tobacco. It begins with a sense of style and fashion but ends up in serious addiction problems. This way, chewing tobacco has risen to be an epidemic in the rural parts of Vadodara and is constantly hampering the public health in the region.

Moreover, to address the other objective associated with this research study, it can be stated that how this epidemic can be dealt with. The Government has already tried strengthening the policies associated with tobacco consumption and have even tried hiking the price of these products. However, according to (Misra, 2016), these measures have not at all affected the usage of chewing tobacco in rural areas. As mentioned before, the subjects or the victims will even buy these products despite of the price hike irrespective of the fact that if they are being able to tend to the actual necessities of life, like buying food, tending to health, etc. Findings suggest that the addiction of chewing tobacco is so severe that the victims in turn cite their using is the priority in their daily chores. Hence, considering all these implications and addressing the issues associated with the usage if tobacco in rural parts of India, especially Vadodara, and Gujarat, it can be stated that it has rose to be one of the major issues that need to be addressed immediately. In this regard, this particular research study helps associate the necessary data as well as information that will in turn provide an overall understanding of the scenario in Vadodara, Gujarat, and how it has become an issue of concern. Therefore, it is of immense significance to emphasize on measures as to how the influence of chewing tobacco is gradually consuming the youth as well as the comprehensive population in rural India.

Methodology

Research orientations are justified on the basis of some important procedure that will help to gather efficient outcomes. Proper research deliverables will have to be selected in order to extract proper research outcomes successfully. Interpretivism research philosophy will be used in order to accomplish proper interpretation and evaluation regarding the research topic. As per the consideration of the chosen research area which reflects about the prevalence of chewing Tobacco in the district of Vadodara, Gujarat, deductive research approach will be chosen. It is evident that this particular approach will significantly assist in determining the deductions from the facts and figures achieved through different potential evidence that are related to the chosen research and the study (Taylor, et al., 2015). Moreover, the research will choose a significant research design procedure so that proper results and findings are determined successfully. In this context, descriptive research design process will be beneficial so as to address proper recommendations prior to the context of prevalence regarding chewing the tobacco in the district of Vadodara, Gujarat. The significance of the research will be accompanied through choosing the actual research strategy. Here the quantitative research strategy where the data are analyzed through statistical results is to be done. Thus considering the research strategy, the primary data for the research will be collected. This particular data will be collected in the form of survey that will be focused upon selecting the participants that generally chew tobacco in the district of Vadodara based on geographical variation. The study will be retrospective as a modified version of a pre-tested, validated and pre-set questionnaire will be used for interviewing about their current and past habit (Bowling, 2014). It is quite significant that a number of 30 participants have to be chosen that chew tobacco in this particular district and 10 close-ended questions will be provided to them where they will reflect about their perception for the prevalence of chewing tobacco. The questionnaires provided to the respondents are provided with options as per the Likert scaling techniques through which ratings from 1 to 5 are directed (Kumar, 2019). Thus the data which will be collected will be significantly analyzed with the help of statistical software Ms Excel and proper responses are to be gathered in order to underpin the assumptions that are important for the research. Random sampling method will be used as it will help to underpin the sample size in a probabilistic approach and choose the participants randomly. 30 sample respondents are to be selected randomly which will participate in the research and clear outcomes from the findings will be justified.

Inclusion criteria: exclusion criteria:

1. Gender: Both (Males and Females) Disable person (physical/ mental)
2. Age: 15 to 60 years. A person with severe illness.
3. Current and past tobacco users

Ethical issues

Prior to the respective research; it is important to determine proper secrecy regarding the data collected through following the data protection act. Prior to the interview, respondents will be explained about the aim of the study, and to assure the confidentiality of the participants’ information, written informed consent will be signed by them. Apart from this, it will be important to maintain cordial relations with the participants and no such personal questions will be asked in order to entail the research properly.

Research Timeline:

The research will be undertaken through following the appropriate structure that are signified through a gnat chart which are showcased below:

1. Timeline
2. Activities Duration
3. Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 Week 7 Week 8 Week 9
4. Introduction
5. Literature Review
6. Methodology
7. Data Analysis
8. Conclusion
9. Recommendation

References:

1. Bowling, A., 2014. Quantitative research: Sampling and Research methods. In: Research Methods in Health. Berkshire: McGraw-Hill Education, p. 217.
2. Barik, A., Rai, R.K., Gorain, A., Majumdar, S., and Chowdhury, A., 2016. Socio-economic disparities in tobacco consumption in rural India: evidence from a health and demographic surveillance system. Perspectives in Public Health, 136(5), pp.278-287.
3. Chatterjee, N., Patil, D., Kadam, R. and Fernandes, G., 2017. The tobacco-free village program: helping rural areas implement and achieve goals of tobacco control policies in India. Global Health: Science and Practice, 5(3), pp.476-485.
4. Govil, S., Dhyani, A. and Mall, A.S., 2016. Compliance assessment of tobacco vendors of Ahmedabad city to India’s Tobacco control legislation. Indian Journal of Community Health, 28(4), pp.374-377.
5. Iacobelli, M., Saraf, S., Welding, K., Smith, K.C. and Cohen, J.E., 2019. Manipulated: graphic health warnings on smokeless tobacco in rural India. Tobacco control, pp. tobacco control-2018.
6. Kahar, P., Misra, R. and Patel, T.G., 2016. Sociodemographic correlates of tobacco consumption in rural Gujarat, India. BioMed research international, 2016.
7. Kostova, D. and Dave, D., 2015. Smokeless tobacco use in India: Role of prices and advertising. Social Science & Medicine, 138, pp.82-90.
8. Mishra S and Mishra M.B., 2013. Tobacco: its historical, cultural, oral, and periodontal health association. Journal of the international society of preventive and community dentistry.
9. Misra, K., 2016. Father of the Pan Masala Industry: Sri Mansukh Lal Mahadev Bhai Kothari. Available at SSRN 2784110.
10. Sakore, D.N., Parande, M.A., Tapare, V.S. and Bhattacharya, S., 2017. Knowledge, attitude, and practice of tobacco consumption among male college students of a rural area of Pune, Gujarat. International Journal Of Community Medicine And Public Health, 4(9), pp.3455-3460.
11. Sidhu, A.K., Kumar, S., Wipfli, H., Arora, M. and Valente, T.W., 2018. International Approaches to Tobacco Prevention and Cessation Programming and Policy among Adolescents in India. Current Addiction Reports, 5(1), pp.10-21.
12. Thakur, J.S. and Paika, R., 2018. Determinants of smokeless tobacco use in India. The Indian journal of medical research, 148(1), p.41.
13. Varshitha, A., 2015. Prevalence of oral cancer in India. Journal of Pharmaceutical Sciences and Research, 7(10), p.845.
14. Kumar, R., 2019. Research methodology: A step-by-step guide for beginners. Sage Publications Limited.
15. Mackey, A. and Gass, S.M., 2015. Second language research: Methodology and design. Routledge.
16. Taylor, S.J., Bogdan, R. and DeVault, M., 2015. Introduction to qualitative research methods: A guidebook and resource. John Wiley & Sons.
17. Fletcher, A.J., 2017. Applying critical realism in qualitative research: methodology meets method. International Journal of Social Research Methodology, 20(2), pp.181-194.
18. Gholap, D.D., Chaturvedi, P. and Dikshit, R.P., 2018. Ecological analysis to study the association between prevalence of smokeless tobacco type and head-and-neck cancer. Indian Journal of Medical and Paediatric Oncology, 39(4), p.456.
19. Niaz, K., Maqbool, F., Khan, F., Bahadar, H., Hassan, F.I. and Abdollahi, M., 2017. Smokeless tobacco (paan and gutkha) consumption, prevalence, and contribution to oral cancer. Epidemiology and health, 39.
20. Warnakulasuriya, S. and Straif, K., 2018. Carcinogenicity of smokeless tobacco: Evidence from studies in humans & experimental animals. The Indian journal of medical research, 148(6), p.681.
21. Reddy, S.S., Prashanth, R., Devi, B.Y., Chugh, N., Kaur, A. and Thomas, N., 2015. Prevalence of oral mucosal lesions among chewing tobacco users: A cross-sectional study. Indian Journal of Dental Research, 26(5), p.537.
22. Odani, S., Armour, B.S., Graffunder, C.M., Willis, G., Hartman, A.M. and Agaku, I.T., 2018. State-specific prevalence of tobacco product use among adults—the United States, 2014–2015. Morbidity and Mortality Weekly Report, 67(3), p.97.
23. Varshitha, A., 2015. Prevalence of oral cancer in India. Journal of Pharmaceutical Sciences and Research, 7(10), p.845.
24. Schauer, G.L., King, B.A. and McAfee, T.A., 2017. Prevalence correlates, and trends in tobacco use and cessation among current, former, and never adult marijuana users with a history of tobacco use, 2005–2014. Addictive behaviors, 73, pp.165-171.
25. Mishra, G.A., Kulkarni, S.V., Gupta, S.D. and Shastri, S.S., 2015. Smokeless tobacco use in Urban Indian women: Prevalence and predictors. Indian journal of medical and pediatric oncology: official journal of Indian Society of Medical & Paediatric Oncology, 36(3), p.176.
26. Bhaskar, R.K., Sah, M.N., Gaurav, K., Bhaskar, S.C., Singh, R., Yadav, M.K. and Ojha, S., 2016. Prevalence and correlates of tobacco use among adolescents in the schools of Kalaiya, Nepal: a cross-sectional questionnaire-based study. Tobacco-induced diseases, 14(1), p.11.
27. Gupta, J., Wesly, S.J. and Gupta, K., 2017. Prevalence of tobacco in Darbhanga district: a hospital-based cross-sectional study. Journal of cancer research and therapeutics, 13(3), p.576.
28. Patel, J., Mubashir, A., Shruti, M., and Maheswar, D.M., 2016. Prevalence of tobacco consumption and its contributing factors among students of a private medical college in Belgaum: A cross-sectional study. Ethiopian Journal of health sciences, 26(3), pp.209-216.
29. Manderski, M.T.B., Steinberg, M.B., Rahi, K.N., Banerjee, S.C. and Delnevo, C.D., 2016. Surveillance of Tobacco Use Among South Asians in the US: Are We Underestimating Prevalence?. Journal of community health, 41(6), pp.1140-1145.
30. Rostron, B.L., Corey, C.G. and Gindi, R.M., 2019. Cigar smoking prevalence and morbidity among US adults, 2000–2015. Preventive medicine reports, 14, p.100821.
31. Gilreath, T.D., Leventhal, A., Barrington-Trimis, J.L., Unger, J.B., Cruz, T.B., Berhane, K., Huh, J., Urman, R., Wang, K., Howland, S. and Pentz, M.A., 2016. Patterns of alternative tobacco product use: the emergence of hookah and e-cigarettes as preferred products amongst youth. Journal of Adolescent Health, 58(2), pp.181-185.
32. Ansari-Moghaddam, A., Rakhshani, F., Shahraki-Sanavi, F., Mohammadi, M., Miri-Bonjar, M. and Bakhshani, N.M., 2016. Prevalence and patterns of tobacco, alcohol, and drug use among Iranian adolescents: A meta-analysis of 58 studies. Children and Youth Services Review, 60, pp.68-79.

Abstract

Background: Tobacco kills over 1 million people annually in India. Tobacco is consumed in various forms across all age groups, gender, and geographic area. To tackle this major public health issue various tobacco prevention and cessation policies and interventions are introduced and implemented by the government.

Aim: The objective of this review is to analyze the success of different tobacco interventions implemented in different states and to assess the awareness of these policies among the population

Methods:

The current review is a result of syntheses of 22 articles.

• Database searched: Ovid Medline was searched for papers with results from different tobacco prevention/cessation intervention programs in different states in India. The search was divided into 3 categories; Location (India and 29 states and 7 union territories), use of tobacco (smoking, pan chewing, tobacco chewing, smokeless tobacco, bidi, cigarette smoking and reverse smoking) and tobacco use cessation (tobacco control, tobacco prevention, smoking prevention, intervention programs, tobacco cessation smoking cessation, health policies, health education). The MeSH terms used for the search were India, smoking, tobacco use cessation
• Article selection: articles were screened based on title and abstract and further based on full text.

Results:

The majority of the interventions included the school-based health program Project Mytri (Mobilizing Youth against Tobacco Related Initiatives) and the community-based program Project ACTIVITY (Advancing Cessation of Tobacco in Vulnerable Indian Tobacco Consuming Youth) show a significant effect on tobacco use outcomes, especially in young adults. The most successful interventions were the ones with continued support from the government and/or NGOs in sustaining the tobacco quit rate. The least successful ones involved Project EX-India and interventions implemented poorly without any framework and follow-ups.

Conclusion: Tobacco use can be controlled by school and community-based interventions, and teachers and community leaders can be trained to make sure there is continued implementation of the strategy. Interventions focusing pregnant women should be explored as most of the current interventions focus on teenagers and men. Intersectoral involvement is required to tackle this major public health issue.

Introduction

The current population of India is 1,364,200,311 and counting out of which only 33.6% live in urban areas and the rest are the rural population and the Indian population is equivalent to 17.74% of the total world. Every year tobacco kills 1 million people, as of now there are 267 million tobacco users in India out of which 20.4% are men and 1.9% are women above 15 years of age (WHO 2018). It is estimated that by 2020 1.5 million deaths will be due to tobacco consumption. Tobacco use prevention and cessation is particularly difficult in India due to consumption of tobacco in various forms and very less support and resources available to control tobacco.

1.2 Various forms of tobacco

India is the 2nd largest tobacco producer after china producing approximately 800 million kgs of tobacco annually. Tobacco production comes under state jurisdiction, yet the 6 sectors of the Union ministry control/has a hand in tobacco production namely agriculture, finance, commerce, labour, industry, and rural development. Tobacco is grown in the following 13 states in India: Andhra Pradesh, Assam, Bihar, Chhattisgarh, Gujarat, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Tamil Nadu, Telangana, Uttar Pradesh, and West Bengal. The most widely cultivated form of tobacco is the Flue-Cured Virginia (FCV) tobacco accounting for almost 40% of the tobacco production and India is the 3rd largest country to produce FVC tobacco after China and Brazil. The other non-FCV tobacco cultivated are LS Burley, air/sun-cured, and oriental tobaccos. Central Tobacco Research Institute (CTRI) conducted a study which outlined that no other single crop will make as much profit as tobacco and growing 2 types of crops together can be a solution to tobacco cultivation and gradually substituting tobacco cultivation ex: tobacco and red kidney beans, tobacco, and garlic have been proven successful. India varies in the tobacco production pattern because of the various forms it is consumed, only 10% of tobacco is consumed in the form of cigarettes and the rest 90% is consumed in other forms namely bidi(sun-dried tobacco flakes are rolled in dried leaves) mishri(a powdered tobacco paste rubbed on gums), paan(betel leaf filled with areca nut, lime and other spices with or without tobacco) and gutkha(areca nut mixed with chewable tobacco). Cigarette smoking had reduced and use of tobacco in other forms has increased from 1980 to 2017 and there is a 33% increase in overall tobacco consumption.

1.3 Tax on tobacco products and export

68% of tobacco is produced by unorganized sectors which are not compliant with all the regulations and they pay less tax due to evasion or tax exemption. Taxes on tobacco products is very less in India compared to other countries, a pack of bidi costs just Rs. 4 (USD 0.058) with 9% tax on retail price, and a pack of cigarette costs 60 rupees with 38% tax on retail price which is below (65% to 80% of retail price the rate proposed by World Bank. Taxes are determined on various characteristics like manufacturer (small vs large scale factory, hand-rolled vs machine-rolled bidis), type of cigarette or bidi (length and filter) and taxes differ by state as well. High rates of smoking not only increase the death rate but also increases the burden on the country’s healthcare system. If no interventions/steps are taken, over 38 million bidi smokers and 13 million cigarette smokers will prematurely die from tobacco-related diseases. Increasing tax on tobacco products will significantly reduce smoking rate and increases government revenue. Studies show that 10 % increase in tax on tobacco products can reduce bidi consumption by 9.1% and cigarette consumption by 2.6%. “If India increases its tax rate on bidis from Rs 14 to Rs 98 per 1000 sticks (from 9% to 40% of retail price) and on cigarettes from Rs 659 to Rs 3691 per 1000 sticks (from 38% to 78% of retail price), 18.9 million lives will be saved among Indians alive today. The increase in tobacco tax will provide the government with an additional Rs 183.2 billion (3.9 billion USD) in tax revenue”(9). India generates approximately 6000 crores of revenue from exporting the wide variety of tobacco leaves and products produced.

1.4 Harmful effects of tobacco

Tobacco kills more than 7 million people annually and 10 million premature deaths and will rise up to 1 billion if no interventions or programs are designed to reduce tobacco use. Tobacco use is more prevalent in men population below poverty level in rural areas and uneducated sections of the society according to national family health survey 3 conducted in 2005 to 2006. The types of health-related problems or also as complex as the type of tobacco products used. Tobacco smoking not only leads to death, but it causes disabilities and diseases, In addition to oral cancer tobacco smoking also causes lung cancer oropharyngeal cancer, cancer of stomach pancreas liver kidney urinary bladder, and bone marrow. Apart from cancer tobacco smoking also causes tuberculosis and in bidi smokers, it causes 2.6 times more deaths than in non-smokers. Smoking is also a major cause for cardiovascular diseases in young age and also 48% of deaths are caused by cardiovascular diseases due to smoking in India.

Cigarettes also contain sugar which is added to remove the harshness of tobacco that makes it less appealing to the youth adding sugar adds flavor to cigarettes and hence is more addictive and easier to use. It increases the risk of diabetes, hypertension, and cardiovascular diseases

Second-hand smoking

Tobacco smoking is not only harmful for the smokers but also to non-smokers who are victims of second-hand smoking. second-hand smoking occurs when a person inhales the smoke emitted from cigarettes or bidi tobacco smoke this can occur at home, at public places (restaurants, bars, offices, bus stands, too name a few), and on streets. Second-hand smoking also causes cancer, cardiovascular diseases, asthma and other respiratory diseases, sudden death syndrome in babies to name a few. The smoke emitted gets settled in furniture, clothes, surfaces in the house, and even the objects used by the smoker and is referred to as thirdhand smoke.

1.5 Tobacco control law

The World Health Organization (WHO) Framework Convention on Tobacco Control (FCTC) binds the countries to implement evidence-based interventions toward tobacco control and cessation and India joined this in February 2004 to implement policies to control tobacco consumption. The FCTC was formulated as a result of the global tobacco epidemic, it stresses on reducing demand and supply of tobacco.

The primary aim of this convention is to protect the present and future generations from declining health, economy, environmental and social impact from tobacco consumption. The protocol consists of articles which consist of regulations for tobacco product production and supply.

The cigarettes and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 or COTPA, 2003 is the principal law which governs the tobacco control in India. This law prohibits smoking in public places and is subject to fine of up to 200 rupees to protect non-smokers from secondhand smoking produced by tobacco products. This law provides rules and regulations for trade and commerce in, and production, supply, and distribution of cigarettes and tobacco products and restrict advertisement of tobacco products if manufacturers do not follow this regulations of production of products related to warnings on the package can be first conviction up to 2 years or fined up to 5000 and up to 5 years in subsequent convictions. Sale of tobacco products are prohibited within a 100meter radius from educational institutions and to any person below the age of 18. Advertisement of any form of tobacco products is prohibited. All tobacco products must display pictorial (skull or scorpion) and written (smoking kills, tobacco causes cancer, and sales of tobacco products is prohibited to a person under the age of 18 years is a punishable offense) warning on the packages.

2. Method

2.1 Search strategy

The current review is a result of syntheses of 22 articles found via Ovid Medline search which was divided into 3 categories; Location (India and 29 states and 7 union territories), use of tobacco (smoking, pan chewing, tobacco chewing, smokeless tobacco, bidi, cigarette smoking and reverse smoking) and tobacco use cessation (tobacco control, tobacco prevention, smoking prevention, intervention programs, tobacco cessation smoking cessation, health policies, health education). The MeSH terms used for the search were ‘India’, ‘smoking’, and ‘tobacco use cessation. Articles were screened based on title and abstract and further based on full text. The keywords were combined with ‘and’ and ‘or’ to retrieve a total of 22 articles were selected

2.2 Inclusion and exclusion criteria

To analyze the success of the interventions only those articles which included smoke and/or smokeless tobacco products usage, tobacco intervention programs implemented in India, articles specifically reporting results in India, interventions which were actually implemented and not just described, and articles not specifically reporting results in India, Incomplete studies, no outcomes mentioned or irrelevant outcomes and articles only explaining intervention programs were excluded.

3. Interventions

3.1 School-based interventions

In the year 2007-2008, the National Tobacco Control Programme (NTCP) was launched by the National Tobacco Control Cell (NTCC) at the Ministry of health and family Welfare (MoHFW) to spread awareness about harmful effects of tobacco use and support people trying to quit tobacco, but this programme did not include any cessation support for schools. Adolescents is the most vulnerable stage in life and most adult smokers start tobacco use in childhood or adolescents therefore it is very important to target interventions at this age group to prevent the use of tobacco. It is very easy to influence young adults through movies, propaganda, innovative advertisements, and peer pressure. The factors which influence and encourage young adults to start tobacco use must be understood to prevent them from initiating tobacco consumption. Indian judiciary has passed laws to prohibit sell of tobacco products within a 100m radius of educational institutions and selling tobacco to anyone below the age of 18 is a punishable offense.

3.1.1 Tobacco-free teacher/tobacco-free society

Teachers are a major role model for their students and for the community as they are a source of knowledge and wisdom and children spend most of their time in schools and are easily influenced by teachers hence school-based interventions involving aiming teachers is an important factor in preventing tobacco usage among the youth. The Indian state of Bihar has rates of tobacco use in the country, it was found that 78% of school teachers in Bihar used tobacco by the Global School Personnel Survey in 2000. A school-based intervention was developed and tested by the Bihar School Teachers Study and was called the Tobacco-free teacher/tobacco-free society program which focused on cessation support, educational and tobacco control policies. The study was conducted in 2 waves 2009-2010 and 2010-2011 and was a collaboration between the Healis-Sekhsaria Institute for Public Health in Mumbai and Patna, India, and the Dana-Farber Cancer Institute and Harvard School of Public Health, Boston, Massachusetts.

• A total of 72 schools were randomized into intervention and control groups and 3 surveys in each wave were collected at baseline, immediate postintervention, and 9 months postintervention, a pilot test was conducted in 2 schools and modified accordingly.
• The intervention was framed around 6 themes: emphasizing teachers as role models, improving the understanding of harmful effects of tobacco, motivation to quit, skill building for tobacco quitting, withdrawal coping mechanisms, and promoting maintenance skills.
• Intervention was delivered through a health educator and a lead teacher was appointed in each school who were trained to deliver the intervention.
• The lead teachers got constant support from the health educators through phone, monthly visits, and a midyear meeting.
• The tobacco policy was painted on each school wall in large and bold writing.
• The intervention included tobacco cessation through written materials and group discussions
• The intervention aimed at increasing the tobacco quit rate post-intervention and after 9 months. About half of the tobacco users quit in the intervention group compared to 15% in the control group.
• The difference between the groups were borderline statistically significant but the effect of intervention was statistically significant with p-value of 0.04.

This intervention was one of a kind and the first one to provide evidence-based cessation program at school level, it was successfully implemented by conducting 98% of the meeting and doubled the quit rate in survey takers, and quadrupled quit rate in those who completed the intervention. Though this intervention does not directly impact the youth it does provide enough material and knowledge to teachers to educate children on harmful effects of tobacco and benefits of quitting tobacco.

3.1.2 Project EX-India

Project EX is a teen tobacco cessation program and has a school-based clinic version and a classroom-based intervention program the classroom-based program was adopted to be implemented in India. The program consists of 8 sessions 40 – 45 minutes each and was based on motivation-coping skills-personal commitment model of teen tobacco users. Alternative medicine activities like yoga, meditation, and healthy breathing were a part of the program and non-smokers become a listening ear for smokers and supported those to decided to quit tobacco and trying not to relapse. 4 schools (2 private and 2 public) in Delhi were selected for the purpose of this project.

The following changes were made to adopt the intervention:

• 2 manuals one for teacher and one for student were translated from English to Hindi for the purpose of implementation of intervention.
• Scenarios and case studies were modified by changing the names and characters for example: changing ‘Eddie’ to ‘Sachin’ and ‘girlfriend’ to ‘best friend’.
• Original curriculum targeted use of pipe, cigarette, and cigar but it was adopted to include various forms of tobacco popular in India including bidi, gutkha, pan, and mishri.
• Currency was changed from dollars to rupees.
• No incentives were given to students for participating in the study as done in the United States.
• Outcome measures were collected before and after the intervention, at baseline demographic characteristics and tobacco use behavior questions were asked.
• Participants were asked to rate which EX curriculum they liked the most out of the total 8 activities: meditation, yoga, breathing exercise, game-is smoking on the menu?, talk shows – cigarettes may be stressing you out, family and friends confront smokers about their habit, quitting smoking: I’ve been there and it does get better and WARNING! Waiting to quit smoking may be hazardous to your peace of mind.
• A third questionnaire was asked after 3 months of intervention consisting of tobacco use behavior yes/no and level of tobacco use questions were asked to assess the effect of intervention.

The program did not have any significant cessation effect, but it most definitely had a prevention effect on young adults and was not conducted long enough (at least a year) to see the impact of intervention.

3.2 Community-based interventions

Most of the Indian population lives below poverty line, most are uneducated and unemployed and have limited access to health care thus it makes it even difficult to have access to any kind of tobacco cessation programs. These community-based intervention programs are funded by the government or NGOs with a good intention to prevent tobacco use in non-smokers and encourage tobacco quitting among smokers. A lot of these interventions are very expensive, time-consuming, and need skills like communication, analysis, and decision-making during the process of implementation as it requires dealing with the local population. There is a lack of evidence-based prevention and cessation programs and if immediate actions are not taken to reduce tobacco consumption rate health disparities will further widen.

3.2.1 Project activity (Advancing Cessation of Tobacco Use in Vulnerable Indian Tobacco using Youth)

Project activity was started in 2009 with 14 low-income communities from Delhi to participate in a randomized intervention trial. These communities were slums and resettlement colonies

References

1. https://link.springer.com/article/10.2307%2F3343371
2. http://www.worldometers.info/world-population/india-population/
3. https://www.smokefreeworld.org/sites/default/files/uploads/derek-yach-press-conference-presentation.pdf
4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3523470/
5. https://apps.who.int/iris/bitstream/handle/10665/42811/9241591013.pdf?sequence=1
6. http://www.fao.org/3/y4997e/y4997e0h.htm
7. https://www.tiionline.org/about-us/introduction/
8. https://www.who.int/news-room/fact-sheets/detail/tobacco
9. https://www.tobaccofreekids.org/assets/global/pdfs/en/India_tobacco_taxes_summary_en.pdf
10. https://apps.who.int/iris/bitstream/handle/10665/272672/wntd_2018_india_fs.pdf;jsessionid=D9F0ED98F62C5B8EA9E5C78342692633?sequence=1
11. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3828698/pdf/AJPH.2013.301303.pdf
12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2898893/pdf/nihms191983.pdf
13. Project EX-India: A classroom-based tobacco use prevention and cessation intervention program