Correlates of nicotine dependence among patients visiting a tobacco cessation centre in India: A retrospective analysis

INTRODUCTION

Tobacco control efforts worldwide have seen progress with 65% of the world’s population covered with at least one MPOWER strategy as per the WHO Framework Convention on Tobacco Control (FCTC). However, the ‘O’ component, i.e. ‘Offer cessation’ has seldom seen progress globally with only two-thirds of all the Parties including tobacco dependence diagnosis, treatment and counselling services in their national tobacco control strategies. Telephone quitline services are also offered in just 39% of the State Parties to the FCTC.^1,2

Tobacco cessation is complex with strategies to target both behavioural and biological phenomena of tobacco, which also exist in the wider sociocultural milieu. Though India has seen a major decline in the tobacco prevalence since a decade with data suggesting 6% decrease between the two Global Adult Tobacco Surveys (GATS), a huge absolute count (>266 million, GATS-2) still poses a challenge.³

The primary substance responsible for sustained dependence and tobacco use is nicotine, which is a highly addictive psychomotor stimulant.⁴ It is often compared with the addiction potential of cocaine, heroin and other substances. Data from the National Comorbidity Survey showed that 32% of all people who ever tried tobacco progressed to nicotine dependence; comparable statistics for heroin, cocaine and alcohol were 23%, 17% and 15%, respectively.⁵

The existing data for nicotine dependence and its associated factors are usually available for smoking and come from American and European countries.^6–8 The problem of tobacco is not as straight as cigarettes in Southeast Asian countries and further made complex with the existing burden of smokeless tobacco (SLT) users and dual users. Therefore, the conventional cessation strategies may need to be modified and thus demand understanding the larger domains that influence the addictive nature of nicotine, which is critical to plan appropriate cessation strategies.

METHODS

Our study reports the findings of 1-year data available at the tobacco cessation clinic (TCC) of a tertiary care public dental hospital. The clinic caters to an average of 5–10 patients per working day and is operational 5 days a week. The clinic was set up in 2011 with an objective to provide brief cessation services to patients visiting the outpatient department of the institute. Tobacco users who attended the clinic over a 12-month period were included in this retrospective cross-sectional study.

Secondary data were obtained from the patient records who had visited the TCC from January to December 2019. The records were initially screened for completeness, accuracy and eligible recorded forms were included in the study. Of the 1436 records, 1144 had all the information needed for the study.

Patient records were obtained from a pre-validated standard TCC patient assessment sheet (PAS), which included various sections: Sociodemographic items (age, gender, educational attainment, place of residence, occupation and marital status, socioeconomic scale as per Kuppuswamy),⁹ tobacco use profile items (type of tobacco, age at initiation, duration of tobacco use, past quit attempts, relapse and current usage per day), nicotine dependence status, strategy used for cessation and follow-up details. For the purpose of the current study, cessation strategies and follow-up details were not included in the final analysis.

Nicotine dependence was assessed by a revised version of the Fagerström test for nicotine dependence (FTND) among smokers¹⁰ and among smokeless tobacco users (FTND-ST).¹¹ The maximum scores were 10 and 16 for the two scales, respectively. Information was collected on self-use of other addictive substances (e.g. alcohol) and family history of tobacco use. A score of 1–3 was considered as low nicotine dependence, a score of 4–6 indicated medium nicotine dependence and a score of 7–10 was categorized as high nicotine dependence.¹²

The proforma was coded with pre-specified criteria and entered into a digital spreadsheet. Data were analysed using SPSS (version 21.0). Descriptive statistics (proportions or means) along with inferential testing using F-tests and χ² tests were used for the outcomes of interest; a p <0.05 was significant.

RESULTS

Of the 1144 proformas, 97.1% (1111) were of men and 2.9% (33) were of women. The mean (SD) age of the sample was 39.8 (11.4) years and of women visiting the TCC was 45.6 (10.1) years.

The majority (83.9 %) were married and belonged to the upper lower/lower scale (50.4%) followed by lower middle (33.1%) socioeconomic class. About half of them were semi-skilled or skilled workers and 8.7% were unemployed. The average working hours were 9.55 (2.75). No significant association was observed with any of the sociodemographic variables and level of nicotine dependence (Table I). Over three-fourths (78.3%; 781) of the sample were either SLT/dual users and the distribution was similar among women with 81.8% (27) being SLT users.

Of 1144 tobacco patients, 48.5% had medium nicotine dependence followed by high nicotine dependence (29.7%) and low nicotine dependence (21.8%). The mean (SD) age of initiation of tobacco for the sample was 26.1 (9.44) years. Women had a higher age of initiation of tobacco (30.9 [12.29] years) compared to the overall sample. A significantly early age of initiation was observed in patients with high nicotine dependence. A similar significant association was observed when greater number of years of tobacco use was associated with high nicotine dependence. The mean (SD) years of tobacco use was 13.6 (10.25) in the sample.

Family history and reason to quit tobacco in the past were not significantly associated with nicotine dependence. However, consuming SLT and use of dual form of tobacco was significantly associated with a higher level of dependence.

About 47% of patients had attempted to quit tobacco in the past and these attempts were significantly higher in patients with high dependence. Alcohol use was reported by only 3.8% of the sample population, however its use was significantly associated with higher level of nicotine dependence (Table II).

DISCUSSION

We assessed the correlates of nicotine dependence among tobacco users visiting the TCC of a tertiary care dental public hospital. The mean age of the patients was 39.8 years with only a small number of women visiting the TCC. The women showed higher age of initiation of tobacco with the majority using SLT. The tobacco use (mainly SLT) among women in Southeast Asian countries including India, is chiefly poverty driven, associated with lower social stigma compared to smoking/drinking, which leads to social/cultural acceptability in women.^13,14

The use of cessation services by women was lower than that by men¹⁵ and a similar pattern has been observed in the use of inpatient healthcare services as well in India.¹⁶ The reasons for such a pattern of healthcare utilization may be too much household responsibilities along with lack of decision-making power and control over resources in the family.¹⁷ Lower utilization of tobacco cessation services may be linked with under-reporting of the habit which is often associated with social and cultural stigma. The lower proportion of women reporting to TCC is in line with studies done by D’Souza et al. and Mony et al. in Bengaluru and Saha et al. in West Bengal.^18–20

The majority of the sample had medium dependence. This was similar to the findings of Parashar et al.²¹

The level of education, socioeconomic status and marital status were not significantly related to nicotine dependence in our study. This is in contrast to the findings of Parashar et al., who reported the lower education and income group being significantly associated with higher nicotine dependence.²¹ The age of initiation was higher compared to findings of GATS-2 (2016– 17), India.²² This observation may be due to geographical and sampling differences in our study where the source of data was hospital (TCC) records. Further high dependence group showed significantly lower age of initiation of tobacco use, which was in line with the findings of Sharapova et al.²³ and Ali et al.²⁴ who did studies among US adolescents.

The SLT and dual users constituted the major proportion of tobacco users in our study, which was in line with national representative data from GATS-2 (2016–17) in India where SLT users were 21.4% compared to smokers (10.7%). The high burden of SLT use in the Southeast Asian region is established, which is home to almost 90% (250 millions) of global SLT use.^25,26

Our study reported that higher proportions of SLT and dual users were classified as medium or high level of dependence compared to smokers. The amount of nicotine delivered in SLT products is extremely high and may range from 1.7 to 76.2 mg per product,²⁷ though there is paucity of laboratory data on SLT and its nicotine dependence.

Overall, less than 50% of users reported family tobacco use, which was in contrast with the findings of Dwivedi et al. who reported 81% users with a family history of tobacco use.²⁸ The family history of tobacco use was higher in the medium and high dependence; however, it was not significant. A positive family history increases the likelihood of uptake of tobacco and thus higher risk of nicotine dependence is already well established.^1,29 The use of tobacco in the family led to normalization of smoke and SLT use; however, due to cultural values/norms the young may not smoke but the same is not appliable to SLT use.³⁰

Around 47% of the participants had made a quit attempt in the past; however, the proportion was slightly higher than the reported national quit attempt rate of 42% for 21 years or older, as per GATS-2. The past quit attempt rate was significantly higher in the high and medium dependence compared to low dependence, which is in line with the findings of John et al. in Germany and Layoun et al. in Lebanon, who reported nicotine dependence was related to a higher number of quit attempts and remaining a smoker.^31,32 A higher nicotine dependence may lead to difficult sustained abstinence and frequent relapse and thus more quit attempts. However, some studies have also reported that low nicotine dependence was an independent predictor of reporting a past quit attempt.³³ A secondary analysis of GATS-2 has also shown that those with past quit attempts had higher odds of willingness to quit in the near future.³⁴

Cessation is a continuous process and relapse is considered a component of it. Nicotine withdrawal is considered an important reason for persistent relapse episodes in tobacco users.³⁵ In our study, craving followed by social/peer pressure was the main reason for episodes of relapse. A greater nicotine dependence has been shown to be associated with tobacco relapse.³⁶ A higher self-reported relapse rate (47%) in our study was similar to the 1-year risk of smoking relapse as reported in a national epidemiological survey.³⁷ Relapse is a common finding in the cessation process and a higher relapse in our study signifies the importance and need of tobacco cessation services in India.

Only a fraction of our sample reported alcohol use, which was low compared to the findings of Gupta et al. in Mumbai who reported 35.6% and 51.1% alcohol use in SLT and smokers.³⁸ The high nicotine dependence group showed greater alcohol consumption compared to the low and medium groups, however the association was not significant.

Though our study presents insights into the factors affecting nicotine dependence in India where tobacco use is made complex by dual use of smoke and SLT products, it presents data from a single TCC and thus may not be extrapolated at the national level. The data were chiefly self-reported and contain inherent social desirability and selective memory bias.

Our study represents itself as a template for further exploring the determinants and correlates of tobacco use and cessation, which may be used at the individual as well as the policy level for effective tobacco cessation strategies among Indians.

Conclusion

Our study explored crucial determinants of nicotine dependence among tobacco users reporting to the TCC. Early age of initiation of tobacco, SLT, greater number of years of tobacco use, presence of previous attempts to quit and alcohol use were significant determinants of higher nicotine dependence. These factors may be incorporated in routine assessment of the tobacco use status and may be used in tailored cessation counselling strategies.