A study to assess the pattern of alcohol and tobacco usage in the rural field practice area of a medical college in Tamil Nadu

INTRODUCTION

Tobacco usage and alcohol consumption is a serious economical setback to the society for ages. Social insecurity and familial disharmony have been the main drawbacks of its usage in the rural area. Today the second largest producer of tobacco in the world is the Indian subcontinent.¹ The World Health Organization estimates that 4.9 million deaths (8.8%) and 59.1 million disability-adjusted life years (DALYs) (4.1%) are attributable to tobacco use every year.² Cigarette smoking is the leading cause for premature death; smoking is the leading cause for cardiovascular deaths, different types of cancers and respiratory problems.³ The constant exposure through second hand smoking (SHS) between the partners results in the causation of diseases, especially in children and pregnancy according to the Global adult tobacco survey (GATS). The smokeless tobacco (SLT) i.e. chewable form has got tobacco with sweeteners, flavourings, and scents which can be quite habitual.⁴

The chewable form of tobacco is in the form of strands, cakes, shreds and the snuff that comes in the dry or moist form and usually dipped between the lips or the cheek.⁴ The smokeless tobacco can cause increased heart rate, blood pressure, altered lipid profile and cardiovascular effects.⁵ The smoking cessation using various strategies done at 30 years of age can reduce the mortality and increase the life expectancy in comparison to non-smokers.⁶ The various types of tobacco used in India are smoking tobacco with cigarettes, beedi, hookah and cigar; chewable tobacco includes paan, gutka, quid, khaini, gul and snuff etc. All these forms are readily available even in the rural population.⁷

In the recent years, the nicotine replacement therapy (NRT) had been popular in the Europe. These are licensed for use mainly in the smoking cessation and smoking reduction. There smoking cessation clinics also had reduced the effects of smoking pattern and its usage.⁸ There is a four-fold risk of NCD in the coming years through 2050. In India, the economic burden from mortality due to various forms of chronic diseases will rise. The prevalence of NCDs can be reduced by the control in the usage of tobacco products in the forthcoming decades.⁹

There are a plenty of chronic conditions when more of it is used and can lead to abuse liability and leads to societal concerns.⁹ In India, 14% of population aged above 15 years smoke tobacco (24% of men and 3% of women).¹⁰

The GATS 2016-2017 survey in India, nearly 19.0% of men, 2.0% of women and 10.7% (99.5 million) adult population smoke tobacco. About 29.6% of men, 12.8% of women and 21.4% (199.4 million) adult population use smokeless tobacco. The second-hand smoke (SHS) was seen in 38.7% of adults who were exposed to second hand smoke at home.¹¹ In Tamil Nadu; 2009-2010, 16.2% of adults; 24.0% of males and 8.4% of females used some kind of tobacco. The smoking habits were observed in 9.6% of adults in which 19.1% were males and 0.1% was females. Around 8.1% of males used SLT (smokeless tobacco). About 9.9% of the individuals had experienced second-hand smoke (SHS) at home.¹²

The tobacco usage can be assessed by a wide range of screening techniques like the Fagerstorm test for nicotine dependence, Youths tobacco survey (YTS), global adult tobacco survey (GATS), and the tobacco assessment questionnaire.¹³ Although, the GATS is a survey tool used by the World Health Organization in various countries with published online reports regularly.¹⁴

The alcohol abuse across the world had caused 3 million deaths every year. Nearly 230 diseases have been associated with alcohol related disorders. In 2018, 6.2 litres of pure alcohol per person 15 years and above consumed the same and in that group, 26% were unaccountable. In India it is comparatively less at 5.5 litres¹⁵. Chronic alcoholism can lead to abnormal liver function test, blood indices and lipid profile leading to various chronic conditions. The blood alcohol level (BAC) of 100 mg/100 ml is considered legally intoxicated in most areas for the charge of driving offense.¹⁶

There are few questionnaires (screening tools) like the Michigan alcohol screening test (MAST), MAST-G geriatric version, CAGE-cut down, annoyed, guilty, and eye-opener, TWEAK- tolerance, worried, eye-opener, amnesia, K-cut down- for pregnant women, adolescent drinking index- ADI and the alcohol use identification disorder test (AUDIT).¹⁷ The above-mentioned questionnaire has got different combinations of sensitivities and specificities respectively. The AUDIT questionnaire has got the highest sensitivity and specificity in the city and urban area than the rural areas in comparison. These tools have been helpful in identifying alcohol related disorders (chronic conditions) and even mental health problems including the withdrawal syndromes and alcohol dependency.¹⁷

The AUDIT questionnaire is finally consolidated with the following grades as low risk, medium risk, high risk and dependency.¹⁸ The world report on alcohol and health status is available in the global status report on alcohol and health 2018, that represents the burden of alcohol consumptions and the economic effect on World Bank income groups.¹⁸

The consumption of alcohol and tobacco leads to medical, social and economic consequences. Hence; the assessment of pattern of tobacco usage and alcohol consumption in adult population is important to estimate the burden and the factors associated with the same on the rural communities. Aim and objective of the study was to study the pattern of alcohol and tobacco usage amongst the adult population in the rural field practice area of a medical college, Tiruchirappalli.

METHODS

A community based cross-sectional study was conducted in the rural field practice area of Trichy SRM Medical college hospital and research centre using the pre-validated, semi-structured questionnaire. After obtaining informed verbal consent the face-to-face interview was conducted using the tobacco assessment form (smoking pattern and quit options) and the AUDIT (alcohol use disorder identification test) form. Based on the prevalence of 40.7% for tobacco usage and 29.6% for alcohol from the previous study by Udayar et al, the sample size was calculated to be 275 by using the formula (1.96)² p × q/d² with an absolute precision of 5%.¹⁹

Inclusion criteria

Adults above 18 years of age who were currently using tobacco products and consuming alcohol.

Exclusion criteria

Those who were not willing to participate in the study. The study population who stopped using tobacco products and consumption of alcohol for the past one year.

The study period was between April and May 2022.The study was started after obtaining ethical clearance from the Institutional ethical committee. The study population was selected using simple random sampling technique from the rural field practice area of Trichy SRM Medical College Hospital and Research centre. After the data collection was done, the data was entered in Microsoft-Excel sheet and analyzed using SPSS software version 26.

RESULTS

In our study the highest number of the study population was in the 58-67 (20.7%) years age group. The male participants were 251 (91.3%) and 24 were females (8.7%). Amongst the study participants majority of them were graduates around 80 (29.1%), the rest were in secondary education in 72 (26.2%) and 70 (25.5%) had higher secondary education.

The main type of occupation was farming/shop keeping in 169 (61.5%) individuals and overall the majority of the socio-economic status belonged to class II modified BG Prasad scale. The nuclear type of family was seen in 182 (66.2%) of the study population (Table 1).

The current study revealed that 98 (35.6%) of the study participants were smoking cigarettes in which there were 91 (33.06%) males and 7 (2.54%) were females. In the beedi smoking there were 50 (18.2%) individuals out of which 44 (16%) were males and 6 (2.18%) were females. About 20 (7.3%) of them smoked cigars and 18 (6.54%) of them were males and 2 (0.72%) were female individuals. In around 5 (1.8%) study participants had mixed habits, 4 of them were males and 1 female. The smokeless tobacco (SLT) was used in the form of snuff in 6 (2.2%) of the individuals, chewable tobacco in 23 (4.4%) and mixed habits in 5 (1.8%) (Table 2).

There were 94 (34.2%) study participants who were not smoking any form of tobacco. There were 133 (48.4%) study participants who smoked between 1-11 cigarettes/cigar/beedi in which 120 (43.63%) were males and 13 (4.72%) were females. Nearly 27 (9.8%) of them were not smoking every day (Table 3).

In the present study around 65 (23.6%) of the study participants never thought of quitting in the last one year, nearly 30 (10.9%) of them thought twice in the last one year and 27 (9.8%) of them thought at least once in last year. In about 92 (33.5%) of them quitting was thought to be very important and 75 (27.3%) of them thought a little is quitting important. Around 45 (16.4%) thought of quitting in less than six months’ time and 66 (24%) of the individuals wanted to quit smoking at some point during the last one year. In about 111 (40.4%) individuals were somewhat confident of quitting and only 36 (13.1%) were very confident in quitting.

In our study there were 101 (36.7%) individuals living with someone smoking at their home which forms a significant number, who had experienced second hand smoking during our study. In the tobacco quitting exercises there are two arms one is the not ready to quit and the other is the ready to quit. Among the not ready to quit nearly 231 (84%) were advised to quit smoking and around 177 (64.4%) were motivated to quit smoking. In the ready to quit arm about 101 (36.7%) were counseled regarding the barriers to quit.

In the AUDIT questionnaire survey we found in about 219 (79.6%) consumed alcohol. Out of which 200 (72.7%) were males and 19 (7%) were females. In nearly 79 (28.7%) consumed alcohol at least 2-3 times a week. In 53 (19.3%) consumed alcohol nearly 4 times a week. In about 45 (16.4%) consumed alcohol less than a month (Tables 4 and 5).

The alcohol drinking characteristics of the study population were as shown in Table 6.

The combined alcohol consumption and tobacco usage was seen in 157 (57.09%) individuals with 141 (51.3%) males and 16 (5.8%). The combined smoke form of tobacco and alcohol consumption was seen in 135 (49%) in which males were 122 (44.4%) and females were 13 (4.7%). In the present study about 30 individuals were illiterate, nearly 100 with primary, secondary or higher education and 52 individuals either with graduation or post-graduation distributed amongst the frequency of tobacco usage. There were only 18 female study participants with increased tobacco usage frequency pattern and were educated.

Association of socio-demographic variables with type of tobacco, frequency of tobacco usage and AUDIT scores amongst the study population:

In the present study, the age distribution, education, occupation, socio-economic status and family type were associated with various types of tobacco usage. Amongst the socio-demographic variables the educational status had significant association with frequency of tobacco usage since p value was less than 0.05 (Table 7).

In the AUDIT questionnaire the age, socio-economic status and the arrangement of the family types were associated with AUDIT scores since p value is less than 0.05. After adjusting for the confounders by applying the multi-nominal regression the socioeconomic status class I, II and III were significantly associated with the AUDIT scores with a p value of less than 0.05 at 95% CI (Table 8).

Figure* denotes p value is significant as it is less than 0.05 at 95% CI

Figure* denotes p value is significant as it is less than 0.05 at 95% CI

DISCUSSION

In the present study in the 58-67 years there were 57 (20.7%) participants in which the total males were 251 (91.3%) and total females were 24 (8.7%). In this nearly 80 (29.1%) were graduated, 72 (26.2%) had secondary education and 70 (25.5%) had higher secondary education. The majority of them belonged to farming and shop-keeping in around 169 (61.5%) study participants. The predominant socio-economic class was found to be class II in 133 (48.4%) individuals. The nuclear type of family arrangement was observed in 182 (66.2%).

In a study conducted by Kumar et al in 2012, in rural Puducherry to estimate the prevalence of Alcohol consumption using AUDIT questionnaire there were nearly 238 (25.16%) individuals in the 58-70 years age group in which males were 495 (52.3%) and females were 451 (45.7%).²⁰ In about 562 (59.4%) individuals had either primary or secondary education and in about 282 (29.8%) had been to higher secondary. The majority of them belonged to class II modified BG prasad scale in 502 (53.06%) individuals. In the study by Kumar et al in 2012, it was found that alcohol consumption was seen in 9.4%, tobacco smoking in 55 (5.8%) and smokeless tobacco in 50 (5.3%).²⁰

In the present study in about 168 (61.09%) used smoke form of tobacco in which 98 (35.6%) were smoking cigarettes with 91 were males (33.06%) and 7 (2.54%) were females. The beedi smoking was observed in 50 (18.2%) in which there were 44 (16%) males and 6 (2.18%) females. The cigars were smoked by 20 (7.3%) individuals with 18 (6.54%) males and 2 (0.72%) female individuals.

In a study conducted by Rajan et al in 2015, with a sample population of 1464, nearly 244 (16.7%) individuals were smoking tobacco in which 191 (13%) smoked beedi and 85 (5.8%) smoked cigarettes. The smokeless tobacco was observed in 168 (11.5%) individuals only.

In the present study the alcohol consumption was seen in 219 (79.6%), out of which 200 (72.7%) of them were males and 19 (7%) of them were females. In about 79 (28.7%) consumed alcohol 2-3 times a week and 53 (19.3%) consumed four times a week. However; alcohol consumption in a study done by Rajan et al in 2015 was found in nearly 207 (14.1%) individuals.²¹

In the study conducted by Rajan et al in 2015 the age, gender and educational status were associated with tobacco usage and alcohol consumption. There were 66 (25%) males in the 45-54 years age group who smoked tobacco and 207 (18.6%) were literates with a p value of less than 0.05. In the alcohol consumption there were 49 (18.6%) individuals with 174 literates with a p value of less than 0.05.²¹

In the present study the smokeless tobacco (SLT) was used predominantly in the form of snuff in 6 (2.2%) individuals and chewable tobacco in 23 (4.4%) study participants. However; in a study conducted by Jain et al in 2018, the prevalence of smokeless tobacco usage in the form of chewable tobacco was seen in 51 (20.4%) rural participants and 35 (14%) of the urban elderly study population.²²

In a study conducted by Sukumaran et al in 2020, using the AUDIT and the ASSIST questionnaire in a study population of 1545, the prevalence of alcohol consumption was found in nearly 146 (9.5%) individuals in which 143 (18.3%) were males and 3 (0.4%) were females (quite few in number). This study concluded with the suggestion of health education in 99 (50%), counseling sessions in 74 (37.8%) and de-addiction in 23 (11.7%) individuals based on AUDIT scoring.²³

In a study conducted by Islam et al in 2016, using the NFHS 4 data, after multivariate logistic regression the age, poor education, occupation, religion, alcohol consumption, marital status and socio-economic status were significantly associated with tobacco usage especially amongst the male population.²⁴

In GATS 2 (2016-2017) India, the prevalence of smokeless tobacco was observed in 31.7%. However; the pattern of smokeless tobacco usage was comparatively less in the present study (6.6%). In our study the second-hand smoke (SHS) was seen in 101 (36.7%) study participants. However; in the GATS Tamil Nadu (2009) the second-hand smoke exposure was observed in nearly 31% of the survey participants.²⁵

Limitations were that it was a cross-sectional study. A sample size of only 275 study participants, and tobacco quitting exercises were not done. The study had predominantly male participants.

CONCLUSION

There was association between all the socio-demographic variables and the usage of tobacco products except for the gender. The age, family arrangement and the socio-economic status were associated with alcohol consumption. After adjusting for potential confounders by doing the multivariate regression it was found that the socio-economic class I, II and III were strongly associated with alcohol consumption. The best and safest way to approach this problem is ensuring health education programs and running de-addiction camps.

ACKNOWLEDGEMENTS

The authors would like to thank field-staff, statistician and CRMI of the Trichy SRM Medical College Hospital and Research Centre, Irungalur, Tiruchirappalli.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee Trichy SRM Medical College Hospital & Research centre, Tiruchirappalli.

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