Predictors of smokeless tobacco use in the adult

Predictors of smokeless tobacco use in the adult population of Karachi ` Karim Abdur Rehman 1, Humna Abid 1, Ramsha Malik 1, Quratulain Merchant, Javaid Khan 2 1 Aga Khan University Medical College, Karachi, 2 Department of Medicine, Aga Khan University Hospital, Karachi

The Europeans introduced tobacco into South Asia in the 1600 s.

GHUTKA roasted chopped tobacco + areca nut + catechu CHALIA areca nut + tobacco + flavouring NASWAR tobacco + lime + oil + ash PAAN areca nut + tobacco + catechu + lime wrapped in betel leaf

Woven into the South Asian culture. . • Use of smokeless tobacco is not considered much of a taboo, as is smoking. • served in social gatherings • psycho-active and addictive substance • A practice in South Asian emigrants. Sullivan et al, Addiction, 2002 97(4)

The tobacco impact. . • An estimate of the number of betel quid users globally is 600 million. • Over 20% of the South Asian population has a habit of chewing smokeless tobacco -Gupta PC et al, Addict. Biol. 2002; 7: 77– 83. -Tobacco Control Fact Sheet 8. International Union Against Cancer, Tobacco and Cancer Programme, Geneva, 1996. - Subramanian, S. V. , et al. BMJ, 2004. 328(7443):

Producing the toxic potion • Heavy metals: cadmium, arsenic, lead • Nicotine • High PH alkaloids • Tobacco-specific nitrosamines are carcinogens formed from tobacco alkaloids - Kazi et al, Environ Monit Assess, 2013 (185: 5199 -5208) - Stepanov et al, Int. J. Cancer, 2005 (116, 16– 19) - Zakiullah et al, Tob Control, 2011

At what cost? • Independent predictor of oropharyngeal cancer • Pre-malignant conditions oral submucous fibrosis - Akhtar et al, Eur J Cancer 2012 - Bile KM et al, East Mediterr Health J, 2010 - Mathers, C. D. et al. PLo. S Med, 2006. 3(11)

• Metabolic Syndrome • Hyperhomocysteinemia • Low birth weight and still births 1 Shafique et al Nutrition Journal 2013, 12: 67 2 Iqbal et al, PLOS one 8(12) Gupta PC et al, Addict. Biol. 2002; 7: 77– 83.

Aims and Objectives The objective of this study was to : i) assess the prevalence of smokeless tobacco use. ii) identify socio-demographic factors and practices that may be associated with its use.

Methods Study design: Cross-sectional study Period: January – March 2011 Design: Convenience sampling Setting: Outpatient clinics of 3 tertiary teaching centers in Karachi • Sample size: 461 • Statistical Analysis: SPSS v 19. 0 • •

Determing smokeless tobacco users • Daily users: consumed atleast once daily • Occassional users: consumed at least once a week • Former users

Inclusion Criteria 1. All adults over the age of 18 Exclusion Criteria 2. Patient refusals 3. Non-permanent residents of Karachi

Dependent Variable: (Outcome variable) • prevalence of smokeless tobacco usage Independent Variables: • age • gender • income • education status • marital status • smoking habits

Results

Smokeless tobacco users 32. 3% smokeless tobacco users female 24% male 39. 2% 0. 00% 20. 00% 40. 00% 60. 00%

REVIEW ARTICLE Year : 2011 | Volume : 55 | Issue : 3 | Page : 199 -209 Sm oke less tob acc o: A maj or pu blic hea lth pro ble m in the SEA regi on: A revi ew Pra kas h C Gu pta 1, Cec ily S Ray 1, Dhi ren dra N Sin ha 2, Po ona m K Sin gh 2 Smokeless tobacco: A major public health problem in the SEA region: A review Prakash Gupta et at Indian Journal of Public Health, 2011 | 55 | : 3 | : 199 -209

Former user (10) 6. 7% Occassional users (34) 22. 7% Daily users (105) 70%

Types of Smokeless tobacco consumed Ghutka (23. 5%) Naswar (20. 8%) Pan (40. 3%) Chalia (21. 1%) Pan Masala (15. 4%)

Awareness Less harmful than smoking 42. 2% Tried to quit 56. 4% harmful 89. 6% 0% 50% 100%

Risk of disease Diarrhea 33. 3% Oral ulcers 87. 2% Cancer 87. 4% Cardiovascular Disease 69. 6% 0% 50% 100%

4 3. 5 3 2. 5 2 1. 5 1 0. 5 0 Adjusted Odds Ratio Male cigarette use primary/secondary graduate education Odd ratio Confidence Interval (95% CI) p value 1. 80 1. 16 -2. 80 0. 008 Graduate 0. 48 0. 26 -0. 90 0. 02 Smoking 1. 85 1. 03 -3. 33 0. 03 Variable Gender Male Education

Discussion

Author Year N Prevalence Variables Sultan A et al 2009 502 family practice clinics in Karachi 52. 4% • Gender: Male>Female (P=0. 03) • Education >10 years (P=0. 001) Khwaja et 2006 al 421 Urban squatter settlement in Karachi 40% • Male gender OR: 2. 46 • Education (P=0. 85) • Knowledge (P=0. 82) Imam et al 2007 1026 6. 4% 3 medical colleges in KPK and Karachi • Gender: Male>female (P <0. 001) • Cigarette use: (P <0. 001) • Boarders> day scholars: (P=0. 02) Valliani et 2012 al 560 Employees at 2 tertiary care centers • Male gender OR: 2. 5 • Illiteracy OR: 1. 7 • Non-paramedic staff OR: 2. 6 Rehman et al 461 32. 3% Patient attendants at 3 tertiary care centers 2011 48% • Male gender OR: 1. 8 • Cigarette use OR: 1. 85, • Literacy OR: 0. 48,

Limitations • A convenience sample • Restricted sample- hospital attendants • Limited number of chewing substances

Conclusion • Male gender, cigarette smoking and education level is independently associated with smokeless tobacco use. • There is a significantly high level of knowledge amongst people regarding the role of smokeless tobacco in causing cancer.

Recommendations • Cigarette smoking is a modifiable risk factor and future work should focus on prevention strategies for all types of tobacco use. • Widespread campaigning is required for health promotion in this subset of the population • Implementation of tobacco legislation laws