Keywords Awareness - health hazards - tobacco - tobacco cessation
Introduction
Tobacco is a South American herb derived from Nicotiana tabacum whose leaves contain 2%–8% nicotine and serve as the source for both smoking and
smokeless tobacco forming the basis of health hazards.[[1 ]] In 1492, Columbus discovered that Native Americans used tobacco for both its pleasurable
effects and for treating diseases. Tobacco was also mixed with equal parts of slaked
lime and was used as a toothpaste by Native Americans. Even in India today, tobacco
powder is used to whiten the teeth and commercially sold as tobacco toothpaste. In
the 1500s, the medicinal property of tobacco was more prevalent in America and Europe.
Only in the 1600s, tobacco faced its criticism as a medicinal herb and ill effects
of tobacco abuse were noted. Around 1828, nicotine was isolated from tobacco and its
medicinal use started decreasing.
In the late twentieth century, tobacco abuse emerged globally affecting all age groups
and increasing the death rates.[[1 ]]
The main component of tobacco, nicotine, causes individuals to become addicted. Nicotine
in small amounts is lethal by nature. Inhalation of nicotine released from tobacco
smoke enters the body and affects all the organs. Nicotine in small amounts simulates
the brain and central nervous system (CNS) and larger amounts depresses the brain
and CNS. Nicotine vapors also increase the blood pressure and heart rate in smokers.[[1 ]] Tobacco use contributes to the majority of oral, larynx, and lung cancers. A 2010
analysis conducted in the US stated that around 9000 premature deaths were caused
by tobacco usage in young people and adults.[[2 ]]
Tobacco causes abnormal DNA methylation in adults leading to cancer.[[3 ]] Oral squamous cell carcinoma (OSCC) which accounts for 90% of cancers in the oral
cavity ranks 8th position worldwide in deaths related to cancers. This trend is more
appreciated in low-income or developing countries than developed countries. OSCC is
regulated by many factors such as age, gender, race, and tobacco habits, among which
tobacco is the main contributing factor.[[4 ]]
The World Health Organization stated that “The tobacco epidemic is one of the biggest
public health threats the world has ever faced, killing more than 8 million people
a year around the world. More than 7 million of those deaths are a result of direct
tobacco use, while around 1.2 million are the result of nonsmokers being exposed to
secondhand smoke.” The mortality rate of tobacco use is calculated to exceed 10 million
by 2030. Tobacco when burned contains 4000 chemical compounds out of which 69 are
carcinogenic in nature.[[5 ]]
Smoked tobacco types include cigars, pipes, bidis, kreteks, waterpipes, and cheroots.
Smokeless tobacco products include chewing tobacco, moist snuff, dry snuff, betel
quid (with tobacco), gutkha, toombak, and dissolvable tobacco. The common misconception
that smokeless tobacco is less hazardous than smoked tobacco leads to abuse of smokeless
tobacco, while both have the same carcinogenic effect.[[6 ]]
Tobacco abuse is hazardous to the world as a whole. Tobacco smoke affects humans of
all age groups irrespective of race and leads to death. Although numerous literatures
in the past two decades enumerate the ill effects of tobacco, the manufacturing and
the consumption of smoked and smokeless tobacco products have only gradually increased.
The main purpose of this present study was to assess the mindset and knowledge of
individuals with tobacco habits regarding the health hazards associated with tobacco
usage.
Materials and Methods
Study design
A cross-sectional study was conducted through an online/manual survey from October
2019 to January 2020 among tobacco users visiting a private dental institution, Chennai.
Study subjects
A simple random sampling was used to select the study participants. The 100 participants
in the study belong to various age groups with tobacco habits.
Inclusion criteria
Tobacco users with current tobacco habits with no history of quitting were included
in the study.
Ethical considerations
Returning the filled questionnaire was considered as implicit consent as a part of
the survey. Ethical approval for the study was obtained from the Institutional Review
Board, Saveetha Dental College and Hospitals, Chennai.
Study methods
A questionnaire of 21 closed-ended questions was prepared and distributed online by
Google Forms. The questionnaire was also prepared in regional language to help individuals
with English as no second language. The collected data were checked regularly for
clarity, consistency, and accuracy. Demographic details were also included in the
questionnaire.
Statistical analysis
The data collected were tabulated in Microsoft Excel 2016 and exported to SPSS software
(IBM® SPSS® Statistics version 24, Chicago, USA). Descriptive statistics to summarize
qualitative data in percentages were calculated. Chi-square test was done to associate
the knowledge of smokers about health hazards of tobacco use. The confidence level
was 95%, with a statistical significance of P < 0.05. The results were presented in the form of graphs and tables.
Results
Out of 100 participants, 92% were males and 8% were females. Fifty-two percent of
the participants were in the age group of 26–35 years, 25% belonged to the age group
of 18–25 years, 13% belonged to the age group of 36–45 years, 8% belonged to the age
group of 46–55 years, and 2% belonged to the age group of above 55 years [[Table 1 ]].
Table 1:
Percentage distribution on knowledge and perception about health risks associated
with tobacco habit
Question
Choices
Percentage
Gender
Male
92
Female
8
Age groups (years)
18.25
25
26.35
52
36.45
13
46.55
8
Above 55
2
Do you currently smoke tobacco on a daily basis?
Yes
87
No
13
How many cigarettes do you smoke daily?
<5
52
5.10
24
>10
24
0
7
How long have you been smoking? (years)
1.5
42
6.10
42
11.15
13
15
3
What type of tobacco product do you use?
Manufactured cigarettes
96
Hand-rolled cigarettes
2
Waterpipe sessions
1
Any other
1
Can long.term smokers reduce their chance of cancer by quitting
smoking?
Yes
74
No
26
Are you aware that smoking leads to both lung and heart diseases?
Aware
76
Not aware
24
Are you aware that smoking affects a nonsmoking person nearby?
Aware
78
Not aware
22
Are you aware of smokeless tobacco?
Aware
54
Not aware
46
Is smokeless tobacco less harmful and lethal than cigarettes?
Yes
50
No
50
Does smoking make you feel better?
Yes
88
No
12
Are you aware that cigarette contains 4,000 chemical compounds of which 69 are carcinogens?
Aware
59
Not aware
41
Nicotine in tobacco is more addictive than drugs like heroin and cocaine?
Yes
53
No
47
During the past 12 months, have you tried to stop smoking?
Yes
42
No
58
Have you visited a health.care provider to quit smoking in the past 12 months?
Yes
17
No
83
Have you noticed the information about the dangers of smoking cigarettes or that encourages
quitting in newspapers or television?
Yes
90
No
10
Have you noticed the health warnings on cigarette packages?
Yes
95
No
5
Do you ignore the health warnings on cigarette packages?
Yes
83
No
17
Do you encourage your friends to smoke?
Yes
24
No
76
If offered help, would you try to quit smoking?
Yes
51
No
49
Eight seven percent of the participants smoked on a daily basis. Forty-eight participants
belonging to the age group of 26–35 years smoked <5 cigarettes per day with P = 0.098 which is statistically not significant [[Figure 1 ]]. Fifty-two percent of the participants smoked <5 cigarettes per day, 24% smoked
5–10 cigarettes per day, 17% smoked more than 10 cigarettes per day, and 7% smoked
1–2 cigarettes per day.
Figure 1: Bar chart depicting the association between the age groups and everyday tobacco use.
Forty-eight of the participants belonging to the age group of 26–35 years smoked <5
cigarettes per day with P = 0.098, which is not statistically significant.
Twenty-eight participants belonging to the age group of 26–35 years smoked <5 cigarettes
per day with P = 0.085 which is statistically not significant [[Figure 2 ]]. Forty-two percent of the participants have the habit for the past 1–5 years, 42%
have the habit for the past 6–10 years, 13% smoke for the past 11–15 years, and 3%
smoke for more than 15 years. Ninety-six percent of the participants use manufactured
cigarettes.
Figure 2: Bar chart depicting the association between the age groups and number of cigarettes
smoked. Twenty-eight participants belonging to the age group of 26–35 years smoked
<5 cigarettes per day with P = 0.085, which is not statistically significant
Twenty-six percent of the participants disagree that long-term users can reduce the
risk of cancer by quitting smoking. Seventeen participants belonging to the age group
of 26–35 years disagree that long-term users can reduce the risk of cancer by quitting
smoking with P = 0.485 which is statistically not significant [[Figure 3 ]]. Seventy-six percent of the participants were aware that smoking causes both lung
and heart diseases. Seventy-eight percent of the participants were aware that smoking
affects a nonsmoking person nearby. Forty-one participants belonging to the age group
of 26–35 years were aware that smoking affects a nonsmoking person nearby with P = 0.091 which is statistically not significant [[Figure 4 ]]. Fifty-four percent of the participants were aware of smokeless tobacco.
Figure 3: Bar chart depicting the association between the age groups and reduced risks of cancer
in long.term users after quitting. Seventeen participants belonging to the age group
of 26–35 years disagree that long-term users can reduce the risk of cancer by quitting
smoking with P = 0.485, which is not statistically significant
Figure 4: Bar chart depicting the association between the age groups and passive smoking awareness.
Forty-one participants belonging to the age group of 26–35 years were aware that smoking
affects a nonsmoking person nearby with P = 0.091, which is not statistically significant
Fifty percent of the participants believe that smokeless tobacco is less lethal than
cigarette smoking. Twenty-two participants belonging to the age group of 26–35 years
disagree that smokeless tobacco is less harmful and lethal than cigarette smoking
with P = 0.384 which is statistically not significant [[Figure 5 ]]. Eighty-eight percent of the participants agree that smoking makes them feel better.
Figure 5: Bar chart depicting the association between the age groups and awareness of lethal
effects of smokeless tobacco. Twenty-two participants belonging to the age group of
26–35 years disagree that smokeless tobacco is less harmful and lethal than cigarette
smoking
with P = 0.0384, which is not statistically significant
Fifty-nine percent of the participants were aware that tobacco contains 4000 chemical
compounds in which 69 are carcinogenic agents. Forty-seven percent of the participants
disagree that nicotine is more addictive and lethal than heroin and cocaine. Twenty-one
participants belonging to the age group of 26–35 years disagree that nicotine is more
addictive and lethal than heroin and cocaine with P = 0.223 which is statistically not significant [[Figure 6 ]]. Forty-two percent of the participants have tried to quit smoking in the past 12
months. Twenty-six participants have tried to quit smoking in the past 12 months with
P = 0.021 which is statistically significant [[Figure 7 ]]. Thirty-seven percent of the participants have visited health-care providers to
quit smoking. Thirteen participants belonging to the age group of 26–35 years have
visited health-care providers to quit smoking with P = 0.082 which is statistically
not significant [[Figure 8 ]]. Ninety percent of the participants were aware of the information about the dangers
of smoking cigarettes. They were also aware of the advertisements in newspapers or
television that encourages smokers to quit smoking. Ninety-five percent of the participants
agree that they notice the health warnings on cigarette packages. Forty-five participants
belonging to the age group of 26–35 years agree that they notice the health warnings
on cigarette packages with P = 0.782 which is statistically not significant [[Figure 9 ]]. Eight-three percent of the participants ignore the health warnings on cigarette
packages. Seventy-six percent of the participants do not encourage their friends to
smoke. Fifty-one percent of the participants agreed that they would try to quit smoking
if help was offered. Thirty-one participants belonging to the age group of 26–35 years
agreed that they would try to quit smoking if help was offered with P = 0.086 which
is statistically not significant [s[Figure 10 ]].
Figure 6: Bar chart depicting the association between the age groups and nicotine property.
Twenty-one participants belonging to the age group of 26–35 years disagree that nicotine
is more addictive and lethal than heroin and cocaine with P = 0.223, which is not statistically significant
Figure 7: Bar chart depicting the association between the age groups and efforts to quit smoking.
Twenty-six participants have tried to quit smoking in the past 12 months with P = 0.021, which is statistically significant
Figure 8: Bar chart depicting the association between the age groups and efforts to quit smoking
by visiting a health-care provider. Thirteen participants belonging to the age group
26–35 years have visited health-care providers to quit smoking with P = 0.082, which is not statistically significant
Figure 9: Bar chart depicting the association between the age groups and noticing the health
warnings on cigarette packages. Forty-five participants belonging to the age group
of 26–35 years agree that they notice the health warnings on cigarette packages with
P = 0.782, which is not statistically significant
Figure 10: Bar chart depicting the association between the age groups and response of participants
to quit smoking if help was offered. Thirty-one participants belonging to the age
group of 26–35 years agreed that they would try to quit smoking if help was offered
with P = 0.086, which is not statistically significant
Discussion
Tobacco derived from N. tabacum is a South American herb primarily used for its medicinal properties in the 1400s.
In later centuries, health hazards of tobacco use were identified after the discovery
of nicotine content in tobacco. When cigarettes are lit, the tobacco smoke emitted
contains nicotine that enters the human body easily and affects the organs. Longer
duration of exposure to nicotine causes neurotoxicity and blood toxicity and alters
the structural architecture of the brain. Tobacco is the main contributing factor
for cancer in the oral cavity.
In the present study, the majority of the participants, i.e., 92%, were males. This
finding is in accordance with the literature by Rani et al. who stated that the rate of prevalence of tobacco usage was 51.3% for men and 10.3%
for women.[[7 ]] The difference of tobacco consumption in gender could be because of the social
and cultural practices in our country, India, and mostly, women belonging to middle-class
backgrounds are not exposed to tobacco products in India. The majority of the participants
belonged to the age group of 26–35 years, followed by the age group of 18–25 years.
Eighty-seven percent of the participants smoke everyday, predominantly smoking 1–5
cigarettes per day. Everyday smoking increases the intake of carcinogens by the smoker,
simultaneously affecting the environment and individuals by passive smoking. This
finding is in accordance with the literature by Schane et al. , who stated that young adult smokers consuming <5 cigarettes everyday have considerably
increased in the past decade.[[8 ]] Apart from everyday smoking, it was also found in our study that the majority of
the smokers were smoking for the past 3–10 years. Chronic exposure to tobacco smoke
increases the toxic levels in the body, simultaneously polluting the air and affecting
other individuals by passive smoking.
There are numerous variants of tobacco available in the market, and it was found in
our study that manufactured cigarettes were predominantly used by smokers. Rationale
to invent machines to manufacture cigarette sticks was an outcome of tuberculosis
occurrence due to spitting of smokeless tobacco. Machines to manufacture cigarettes
were patented in the 1880s by James Bonsack. Ever since, the use of manufactured cigarettes
rather than smokeless tobacco evolved.[[9 ]] The downside of using manufactured cigarettes apart from tobacco smoke is disposal
of the cigarette sticks postconsumption. Cigarette butts constitute about 30% of total
litter globally. The most common method of cigarette butt disposal is nearby water
bodies or empty grounds. Nicotine, heavy metals, and polycyclic aromatic hydrocarbons
found in cigarette butts leak into the water and soil harming the environment and
aquatic organisms. Freshwater species are known to be more affected by these chemical
agents. The paper and other materials used for manufacturing cigarette packages also
sum up for trillions of unwanted solid waste and potentially affecting the environment.[[10 ]]
In our study, it was found that the majority of the participants were aware that quitting
smoking in long-term smokers cannot reduce cancer risk. From the initial days of smoking,
the tobacco smoke enters the body and affects the organs. Individuals who quit smoking
at younger ages have higher rates of improving their health conditions. Individuals
with a history of cancer are susceptible to cancer recurrence and long-term side effects.
Damage caused by smoking is irreversible, but quitting smoking alters the health,
reduces cancer risk, and improves the quality of life by 10 years.[[11 ]] Misconception about immediately recovering health after quitting smoking should
be addressed. The striking feature of our study is that the majority of the participants
were aware of passive smoking. However, not many participants were aware of ill effects
of smokeless tobacco. Literatures provide evidence that smokeless tobacco has the
same carcinogenic effects as smoking cigarettes. Aboaziza and Eissenberg state that
consumption of Waterpipe tobacco smoking is gradually increasing globally due to the
lack of knowledge of nicotine content in tobacco smoke. This abuse of smokeless tobacco
increases the intake of tobacco vapors in smokers.[[12 ]]
Forty-seven percent of the participants disagree that nicotine in tobacco is more
addictive than cocaine. This finding is in accordance with the literature by Roh who
states that nicotine does not induce intoxication like caffeine or other drugs and
cannot be addictive. Smokers with withdrawal symptoms tend to resume smoking due to
changes in the structural patterns in the brain and not due to nicotine.[13] Despite
the awareness about tobacco causing ill effects to self and others, only 42% of the
participants in the present study have tried to quit smoking and only 17% of the participants
have visited a health-care provider to quit smoking in the past 12 months. Predominantly
95% of the participants notice the health warnings on the cigarette packages, and
majority of them ignore the warnings. Emily T Hebert states that social media have
an impact on delivering knowledge to young adults and high school children and might
become an essential tool in reaching out to more population.[[13 ]]
The authors acknowledge the presence of study limitations such as lesser sample size.
The participants included were those with tobacco habit only, and knowledge regarding
tobacco health hazards should also be evaluated in nonsmokers.
Conclusion
The present study provides an insight that even though the majority of the participants
were aware of health risks associated with tobacco use, they chose to continue the
tobacco habit. The negligence and ignorance is due to environmental issues surrounding
the individual where smoking has become a common habit. Decreasing the rates of cigarette
manufacturing and increasing the counseling of the vendors to limit the supply of
cigarette packages to young people could be a revolutionary start in making this world
tobacco free.
