Tobacco Awareness, Consumption Patterns, Sociodemographic Factors, and Non-Communicable Disease Linkages in Urban Central India

Introduction

Tobacco consumption has been significantly associated with increased mortality and morbidity.¹ The World Health Organization (WHO) ’s global target is to reduce tobacco use by 30% by 2025.² According to the National Family Health Survey 5 (NFHS 5) data of India, the prevalence of tobacco use in any form among women and men is 8.9% and 38% respectively.³ According to the Global Adult Tobacco Survey 2 (GATS), a significant portion of the adult population in Chhattisgarh, a state in Central India, uses tobacco.⁴ The NFHS 5 Chhattisgarh data shows that the percentage of women and men who used any tobacco was 17.3% and 43.1% respectively.⁵ This percentage was higher in urban areas than in rural areas. A study by Verma et al., found that the mean age of initiation for smoked tobacco and smokeless tobacco (SLT) in India increased between 2009-2010 to 2016- 2017.⁶ Despite many efforts and guidelines, awareness about the full spectrum of harmful effects of the usage of tobacco of all varieties remains poor, especially among women even if women are the highest users of smokeless tobacco in Central India.⁵

The use of tobacco has been linked to almost all types of noncommunicable diseases. Tobacco addiction can cause psychological and physical cravings with mental health disorders. Frequent users of tobacco often have lower immunity and are prone to infections.⁷

The literature review prior to the study revealed very few studies on tobacco awareness in Chhattisgarh, Central India. Most of the population, except health-related professionals, are not aware of the full range of harm from tobacco product use and thus tend to underestimate the impact of tobacco on their ill health. Hence, it is the need of the hour to increase awareness about the adverse effects of tobacco addiction.

Some Tobacco cessation and control guidelines are the COTPA Act, the World Health Organization’s Framework Convention on Tobacco Control (FCTC), the MPOWER strategy, pictorial tobacco warnings guidelines, etc. The National Tobacco Control Program (NTCP), launched in 2007-08 by the Government of India, aims to reduce tobacco consumption, raise awareness, and enforce tobacco control laws under COTPA.⁸ By the 12th Five- Year Plan, NTCP was expanded to all 36 states/UTs, reaching 612 districts, and successfully reduced tobacco use by 8.1 million people.⁹ The National Program for Noncommunicable Diseases (NP-NCD) has also included screening for tobacco addiction and chronic respiratory diseases by frontline workers.

Materials and Methods

This was a community-based, cross-sectional study conducted in an urban area of Raipur, Chhattisgarh, India, in 2023-2024. The sample size was calculated using the formula Z2 P(1-P)/d2, where Z = 1.96 at a 5% level of significance and d is the absolute precision at 5%. The highest prevalence of tobacco use in Chhattisgarh was reported in NFHS 5 as 43.1%, and using this, the minimum sample size was 377.5. Data from 408 individuals were included in the study. The inclusion criteria were individuals aged 40-59 years (middle-aged) and ≥ 60 years (old age), residing in the area for more than 6 months. Individuals who were unavailable during the visits, too sick to interact, or with impaired comprehension were excluded from the study. The study was conducted in the urban field practice area (Zone 7) of a tertiary care hospital in Raipur, India. Data collection was done by house-to-house visits in the community. Households were selected using simple random sampling. Various methods, like rotating bottles to choose a street and lottery methods to select participants, were used. Only one participant was taken from each house.

Operational definitions were evaluated before the start of the study, including cut-off criteria for diabetes (WHO guidelines), hypertension (JNC 8), waist to hip ratio, body mass index, etc. Overcrowding was assessed using the person per room and room area criteria. All smokers smoking during the study period and all those who had quit smoking less than one year before the assessment were considered current smokers.¹¹ Similar definitions were used for smokeless tobacco users.

A semi-structured questionnaire, adapted from the WHO STEPS survey and the Global Adult Tobacco Survey (GATS) version 2, was used in the study. Questions on passive smoking exposure were also included. The questionnaire was pilot tested in the Amanaka area of Raipur, India, to identify and correct errors. Details were collected on the sociodemographic profile, addiction history, history of chronic diseases, treatment history, anthropometry measurements, etc. Tools used were inextensible measuring tapes, a digital weighing machine, an Omron Glucometer, a stadiometer, a digital sphyg-momanometer, etc. A portable glucometer measured random blood glucose levels to detect Type II diabetes in those with no prior history. ^12,13

Statistical Analysis

Data was compiled in Excel sheets and analyzed using IBM SPSS software version 27. All the categorical variables were expressed as frequencies and percentages. The continuous variables were summarized using various measures of central tendency, such as the mean, median, mode, standard deviation, and interquartile range. Initially, the chi-square test of significance was used to test the association between tobacco awareness and other independent variables. Independent Sample T test and One-Way ANOVA test were applied to find out the mean and SD of continuous variables. Any P value < 0.05 was taken as significant, and <0.001 was taken as highly significant. After ruling out multicollinearity (via Pearson's Correlation test) and applying goodness of fit tests, the significant variables from the Chi-square test were included in a binary logistic regression analysis to estimate crude odds ratio (OR) and adjusted odds ratio (AOR). 

Results

Tobacco Consumption Patterns Among the Study Participants

Smoking

The prevalence was high among males, with 24.2% currently smoking. A significant association was present between gender and smoking status (P value <0.05) (Figure 1).

Among the smokers, most of the participants smoked one type of smoking product, preferably. The most common type of smoking product, preferably. The most common type of smoking product used was Bidis or Hand-rolled Cigarettes (Figure 2).

Out of the 45 smokers, 12 used ≤2, 14 used 3 to 4, and 19 used ≥5 cigarettes/bidis per day. The mean years of smoking among them was 27.8 ± 1.727 years.

Smokeless Tobacco

Many of the participants used multiple smokeless tobacco products. 58.8% of males and 45.6 % of females were habitual smokeless tobacco users. A significant association was found between gender and smokeless tobacco consumption, with a P-value <0.05. Gudakhu was the most commonly used smokeless tobacco product, especially among women (40.3%).

About 67.2% of current tobacco users and 68.8% of past tobacco users were literate. Most current and former tobacco users belonged to the upper, lower, and lower-middle SES groups. About 26 participants used both smoking and smokeless tobacco products. Using the Chi-Square test, a significant association was found between age, gender, education, and SES and overall tobacco consumption.

Among 182 males, 69.3% consumed tobacco in some form. 10.4% of males are past users, and 20.3% did not use tobacco in any form, smoking or non-smoking. Among 226 female participants, 45.6% were current tobacco users and 5.8% were past users.

Passive Smoking

In this study, passive smoking was assessed using a Likert Scale of exposure from daily, weekly, monthly, to less than monthly (equivalent to no exposure), adapted from the GATS (Global Adult Tobacco Survey 2020) questionnaire.

About one third of the participants (34.3%) reported having been exposed to passive smoking. Among 182 males, 86 (47.3%) were exposed to passive smoking, and among 226 females, 54 (23.9%) were exposed. About 27.9% of participants had daily exposure to passive smoking.

Tobacco and Alcohol Co-use

The prevalence of alcohol consumption was 17.1% in the study population. Overall, tobacco consumption was found in 58 (82.9%) of the 70 current alcoholics. Among the 310 non-alcohol users, 149 (48.1%) were current tobacco users. Furthermore, among the 28 past alcohol users, 22 (78.6%) were also using tobacco. The mean quantity of alcohol consumption was 149.43 ± 66.8 ml per session of drinking, with a range of 240 ml.

Overall, tobacco consumption had a significant association with alcohol consumption (P value <0.05).

Tobacco Awareness Among the Study Participants

Among the 408 people interviewed about tobacco awareness, 248 responded yes. However, when asked to elaborate on the harmful effects of tobacco, only 233 (57.1%) people could give correct responses and were included in the “ Aware’’ group. The rest 15 out of the 248 either could not answer the following question or gave incorrect responses. Some of the incorrect responses were malaria, dengue, leprosy, etc.

Sources of Tobacco Awareness

Participants were asked about various sources of information on tobacco awareness. It was a multiple choice question (Figure 3).

*The “other sources’’ of information were school/ education (15, 3.7%), friend, relative, or family member with cancer history (11,2.7%), rally (7, 1.7%), cigarette packets (5, 1.2%), quack (2, 0.5%), and religious sermons (2, 0.5%).

Responses to Harmful Effects of Tobacco Question

Among the 233 participants in the Tobacco Aware group, cancer emerged as the most recognized harmful effect, reported by 215 participants (92.3%), including specific mentions of oral, lung, and head-and-neck cancers. Lung-related conditions were the next most common, with 73 participants (31.35%) citing diseases such as TB, asthma, or COPD. Other reported effects included dental problems (6.9%), mouth odor (3.0%), mouth ulcers or cheek swelling (4.7%), infertility (3.4%), PCOS/acne (1.3%), addiction (4.3%), heart diseases (4.3%), stroke or paralysis (2.1%), myalgia or fatigue (1.7%), reduced longevity (1.7%), and burning feet (0.4%).

Table 2 demonstrate the association of tobacco awareness with different variables using regression analysis.

Variables that were significant in Table 1 were tested for multicollinearity and subsequently entered into a binary logistic regression model. After applying Goodness-of- Fit tests, all variables were analyzed together in Model 2, adjusted for covariates. Age, education, socioeconomic status (SES), overcrowding, and exercise remained significantly associated with tobacco awareness (P < 0.05). Older participants showed lower awareness (AOR 0.427, 95% CI 0.224-0.815, P = 0.01). Literate individuals were more aware than illiterate individuals (AOR 0.363, 95% CI 0.195-0.677, P = 0.001). Participants from higher SES had greater awareness (AOR 3.868, 95% CI 1.727-8.662, P = 0.001). Those living in overcrowded conditions were less aware (AOR 0.579, 95% CI 0.302- 0.969, P = 0.040). Individuals who exercised regularly also demonstrated higher awareness (AOR 0.541, 95% CI 0.302-0.969, P = 0.039). No significant association was observed between hypertension and tobacco awareness in the adjusted model.(Table 2)

Discussion

In a study by Rupani et al., in India in Bhavnagar’s urban slum, 27.3% of individuals used smokeless tobacco (SLT), with addiction being the primary barrier to quitting.¹⁴ A cross-sectional study by More et al., in Mangalore found that awareness was high about oral cancer, tooth staining, and dental implants, but there were gaps in knowledge about gum disease and wound healing.¹⁵ This is similar to the current study, where only 57% participants were aware of the harmful effects of tobacco. Lakra et al., found that oral cancer patients in north India were unaware of early signs of oral cancer, with many continuing tobacco use.¹⁶ The majority came from lower SES backgrounds; thus, there is a need for improved education on prevention. In Kapoor et al., after training security guards, awareness of tobacco laws increased from 20% to over 80%.¹⁷ Two-thirds of participants were aware of COTPA Section 4, and 33.6% of tobacco users and 58.4% of observers knew about Section 6b. Raman et al., in South Chennai, found that 33.2% of respondents did not change their behavior after viewing tobacco warning ads.¹⁸ Additionally, 90.3% of participants were unaware of professional help for quitting.

Subasinghe et al., conducted a hospital based study in Sri Lanka. They found that tobacco consumers are more likely to be aware of the harmful effects of tobacco use than non consumers (OR 1.11, 95% CI 0.45-2.74).¹⁹ The Swatan et al. study on tobacco smoking addiction in rural Indonesian communities identified key determinants such as peer influence, lack of awareness about health risks, and cultural norms that encourage smoking.²⁰ This is similar to the findings of the current study.

In our study, the majority of respondents knew about cancer as an adverse effect, but knowledge about the harmful effects of tobacco on other organs was poor. A 2022 survey in Poland by Szymanski et al., found high awareness of tobacco-related diseases.²¹ In the study by Ranney et al., in June-July 2021, on U.S. adults, awareness of health risks from alcohol and tobacco couse ranged from moderate (e.g., throat cancer at 65.4%) to low (e.g., colorectal cancer at 23.1%).²² King et al., in Australia found that while most participants recognized smoking’s risks, only a quarter accurately quantified the mortality risk.²³ Public support for local tobacco policies is essential. Brief, tailored messaging can shape public understanding of nicotine-related risks and encourage healthier behaviors as shown in Rhoades et al., Villanti et al. and Peterson et al. ^24-26 Agaku and Filippidis’s study found that 24.4% of school personnel across 29 African countries were unaware of the health consequences of tobacco use.²⁷ Low education and lack of tobacco control training were significantly associated with unawareness, similar to the current study.