Tobacco Awareness with Socioeconomic Status and Pictorial Warning in Tobacco Cessation: An Exploratory Institutional Survey in a Semi-urban Population

INTRODUCTION

Tobacco epidemic is one of the biggest public health threats the world has ever faced, killing more than 7 million people a year, a figure that is predicted to grow to more than 8 million a year by 2030 without intensified action. More than 6 million of these deaths are the result of direct tobacco use, while around 890,000 are the result of nonsmokers being exposed to second-hand smoke.¹ India has 11.2% of the world’s total smokers 1 million tobacco-related death every year.² Tobacco users in any form develop serious illness, die prematurely, deprive their families of income, raise the cost of health care, and hinder economic development.^3,4 Smokeless tobacco products and betel quid with or without tobacco are the major risk factors for oral cancer in India. Delayed presentation of oral cancer is mainly due to lack of awareness of the public about oral cancer and its associated risk factors. Health warnings on tobacco products can be very strong and cost-effective way of making people aware of hazardous effects of tobacco. Unlike many other products, tobacco packaging is not removed and discarded but is used as a container until the contents have been consumed; it thus provides high reach and frequency of exposure to users.⁵

As per article 11 of the World Health Organization Framework Convention on tobacco control (2003) guidelines, health warnings must be clear, large, rotating, and should cover at least 30% of the front and back of cigarette packages. Besides these minimum requirements, it must cover at least 50% or more of a package’s principal surface area and may include pictures.^6,7 India is the third among countries with largest pictorial warnings on tobacco products.^8–11 Although pictorial warnings displaying oral cancer risk has been placed on tobacco products, yet these warnings are ignored, and tobacco is consumed on a large scale. The socioeconomic status (SES) is an important determinant of health, nutritional status, mortality, and morbidity of an individual, influencing the accessibility, affordability, acceptability, and actual utilization of available health facilities.¹² Modified Kuppuswamy socioeconomic scale is commonly used to measure the SES in the urban communities. The scale includes the education, occupation of head of the family, and income per month from all sources.¹³ Early detection, which comprises screening of asymptomatic populations and increasing awareness of public regarding early signs and symptoms, increases the probability of cure. Little is known about the awareness regarding ill effects of tobacco in Indian population. Hence, this study was designed with an aim to explore the knowledge of ill effects of Tobacco and the Impact of pictorial warning on tobacco cessation with extensive objectives which includes to estimate the prevalence of tobacco users at a given period of time, to study the knowledge and awareness of the ill effects of tobacco on oral and general health, to estimate the pack years, to correlate the tobacco awareness with SES, and to evaluate the effectiveness of pictorial warning on tobacco cessation.

MATERIALS AND METHODS

This study was designed and carried out at Department of Oral Medicine and Radiology, SRM Dental College and Hospital, Ramapuram, Chennai, Tamil Nadu, and was approved by the Institutional Ethical and Scientific Committee Board. The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional or regional) and with the Helsinki Declaration of 1975 that was revised in 2000.¹⁴

RESULTS

The study covered a total of 300 subjects. Of these, 75.7% were males and 24.3% were females. The mean age in males and females was found out to be 40.7 and 43.8, respectively. With respect to the place of residence, 66.2% were from urban, while others (33.8%) had a rural background but settled in Chennai. The percentage distribution according to the SES was found out to be 18.3%, 37.7%, 12.0%, 17.7%, and 14.3% in Class I (upper class), Class II (upper middle), Class III (lower middle), Class IV (upper lower), and Class V (lower), respectively. The percentage prevalence of education, occupation, and income of the respondents is illustrated in Figures 1 to 3, respectively.

DISCUSSION

There are only few studies conducted in the past to assess dental patient’s knowledge and awareness of ill effects of tobacco on health. Moreover, most of the available studies have focused on either smoking or smokeless form of tobacco leading to oral cancer, and on knowledge and attitude of tobacco use among health professionals.¹⁵ In contrast to these studies, our study assessed awareness of ill effects of tobacco not only on oral health but also on general health, and after assessing their awareness, every tobacco user was subjected to Questionnaire 2 to evaluate the role of pictorial warning in tobacco cessation along with personal suggestions/opinion on warning signs. In this context, this study is an important addition to the existing literature. For effective implementation of tobacco control, knowledge regarding the awareness, attitudes, and practices of the population toward tobacco is necessary.¹⁶ Our study had 75.7% of males and 24.3% of females which is not in accordance with the study conducted by Tirukkovalluri et al.¹⁷ and Madappady et al.,¹⁸ as the former study was conducted only on migrant male workers in Chennai, and the latter tobacco awareness study was conducted among medical students. In our study, awareness level is significantly higher in men than in women which is in accordance with Yang et al.¹⁹ However, this cannot be relied on the whole as majority of our study population were males. On the whole, this study reported good awareness about harmful effects of tobacco which is in accordance to the study conducted by Dhadwal and Kaushal in Shimla city¹⁶ and Tirukkovalluri et al.¹⁷ in Chennai population and not in accordance with the study conducted by Ibrahim et al. in Mangaluru, as the study was designed in a student population.²⁰ The general awareness regarding ill effects of tobacco on oral and general health was observed to be more in Class I (upper class) and in the younger age-groups (<35 years). It is also noteworthy that for increased level of education, there was increased awareness. The abovementioned findings should not be considered contradictory because the highest level of education assessed in this study were ‘at least graduates’ and by the time the subjects completed their graduation they were mostly less than 35 years of age, which is in accordance with Agrawal et al.⁴ Furthermore, increased awareness of the younger age-group can also be attributed to the wide media exposure, usage of android phones with WhatsApp, and different anti-tobacco campaigns in recent years. Young people start smoking to enhance their social status, relieve anxiety, for stimulation, out of curiosity, or peer pressure with availability of extra money. Indeed, many smokers start smoking for entertainment purposes and curiosity for initiation.²¹ Around 20% of our study population were not aware that tobacco causes heart diseases and lung cancer, and around 10% were not aware that tobacco usage can cause infertility and impotence. Less than 10% are not aware that tobacco usage can cause dental problems. More than 40% of participants in class IV and V were aware that cigarette smoking, beedi, chewing tobacco, and beetle nut and leaves are injurious to health. According to Global Adult Tobacco Survey (GATS) 2016–2017, in India, 92% of adults believes that smoking causes serious illnesses and 96% believe that smokeless tobacco can cause serious illness.²² In our study, the prevalence of regular smokers was 24.3% which is in accordance to the study conducted by Sunil Kumar et al.²³ In another study conducted by Kaur et al. in rural areas of Tamil Nadu, it was observed that prevalence of tobacco use among males was 60.7%, while 15.1% of females used tobacco at least once in a lifetime. However, this study cannot be compared with ours with respect to study duration, as ours is a 1-week survey.²⁴ A much less prevalence of tobacco use was observed in a study conducted in rural, semi-urban, and urban areas of Chennai by Chockalingam et al. The overall prevalence in the rural area was only 23.7% which is almost coinciding with the results of our study.²⁵ In our study, %3E;30% have never practiced oral self-examination which is in accordance with the study conducted by Pai et al.¹⁵ Thus, majority of tobacco users were not paying attention to their oral health and are also not interested to look inside their oral cavity for any precancerous changes. This raises the high need for increasing the awareness among mass populations on effects of tobacco on oral, general health, and precancer. A study conducted by Elango et al. showed that awareness of oral cancer and its risk factors after introduction of mouth self-examination program was over 80%.²⁶ Our study showed significant difference between pack-years (chewing tobacco) and SES in ANOVA inferring that chewing tobacco was prevailing in all the sub-classes. Tukey HSD post hoc tests also showed statistical significance in pack-years (chewing) between class II and class V. More than 90% of our participants were aware that tobacco in any form can cause oral precancer and oral cancer which is in accordance with the study conducted by Agrawal.⁴ In our study, 92% were aware that changes in lifestyle reduces the risk of oral cancer which is in accordance to the study conducted by Agrawal et al.⁴ These findings corroborate earlier findings, which report that mass media is a common source of information regarding oral cancer (Ariyawardana and Vithanaarachchi 2005; Petty and Scully 2007; Amarasinghe et al., 2010; Srikanth et al., 2011). In addition, housewives and retirees also spent more time socializing with either friends, neighbors, or community groups from who they could have heard about oral cancer.²⁷ Prabhakar et al. conducted an awareness study on passive smoking in Chennai population and found out that the respondents were very well aware that passive smoking is spread through smell and the duration of exposure increases the intensity of passive smoking, which is not in accordance with our study. In our study, 34.3% have never heard about passive smoking. This difference could be attributed to the sample and methodology of both the studies, since ours is a face-to-face individualized study, and the former was designed through google forms, where participants could have cross checked and verified the answers through google search, leading to bias.²⁸ Ogawa proved that pregnant women who have been exposed to passive smoking have low birth weight infants.²⁹ Martin stated that Passive smoking has more effects in children than in adults.³⁰ In all, 97.4% of the respondents to Questionnaire-2 have tried to quit tobacco usage which is in accordance with the study conducted by Shomar et al. in Gaza, Palestine,²¹ and 90.3% of our respondents to Questionnaire-2 were not aware that a professional help is available to motivate quitting and whether such center existed which is also in accordance to the study conducted by Shomar et al.²¹ In general, smokers were more aware than smokeless tobacco users and tobacco users emphasized the importance of pictorial warning and recommended a greater area to be covered for pictorial warnings and to increase the frequency to change the pictorial warning signs. Also, people continue smoking despite the awareness of ill effect of usage due to their addiction which is in accordance to the study conducted by Srikanti Raghu in Guntur.³¹

Few suggestions from respondents regarding pictorial warning includes frequent change in warning signs every 3 months, to include more text, to increase the cost of tobacco products, self-control, etc. A successful image is about communication as most of the information transmitted to the brain is visual; it must tell the viewer the intended story through an entirely and solely visual means of communication. The visual portion has much more immediate impact than the text because text requires conscious processing and images do not, which facilitate to empower people to make strong associations between health messages and their perceptions. Integrating efforts of multidisciplinary teams are required to design more effective behavioral change communication strategies. There is a need to improve the awareness regarding deaddiction methods and programs. To date, far more attention has been focused on prevention rather than cessation, especially in low- and middle-income countries. The literature suggest that tobacco users would like to quit, although only less than 10% of them are successful in a given attempt, and a simple advice from a physician has been shown to increase abstinence rates when compared to those with “no advice”. Thus, studies clearly indicate the challenge and need of raising knowledge and skills of faculties, students and the paramedical staff about the harmful effects of tobacco use and its cessation; and culturally appropriate style of counseling the patients.^18,32

The limitations of this study include the sample size, points, and study duration and hence cannot be generalized to entire Chennai population. The sampling method might have introduced selection bias of the respondents. However, to minimize this, patients were selected only for 1 week to conduct this survey, considering that this could be one way of capturing different population demographics within a limited sampling time frame. Moreover, the sample captured was representative of the Tamil population where it is consisted of an ethnic profile that is in accordance with the country’s population profile. Another limitation relates to the comprehensibility of certain phrases in the questionnaire, for example, “oral cancer” and “oral self-examination”. However, to minimize this bias, a pretest was conducted. Since it was a quantitative study, few variables like reasons for tobacco usage could not be assessed properly. Also, smoking is a socially and culturally unacceptable habit; hence, people are less likely to report it which may lead to underreporting and in turn to decrease prevalence.

CONCLUSION

This study is a pioneering attempt at the grass root level in a high-risk semi-urban group, and the results clearly indicate that regardless of the good awareness of health problems related to tobacco use, the usage was high among our population in South Chennai, and tobacco awareness was relatively deficient in lower class, which is not satisfactory. This calls the need for more awareness programs in the targeted population specially directed toward the control of the risk factors. Health warnings on tobacco packages that combine text and pictures, along with role of mass media and oral self-examination can effectively increase public awareness of the serious health risks of tobacco use and to reduce its consumption.

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