|Year : 2017 | Volume
| Issue : 4 | Page : 327-335
Profile of tobacco users amongst treatment seekers: A comparison between clinic and community sample
Savita Malhotra, Abhishek Ghosh, Neeraj Kakkar
Department of Psychiatry, Post-graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||17-Nov-2017|
Professor and Head, Department of Psychiatry, PGIMER, Chandigarh
Source of Support: None, Conflict of Interest: None
Background and objectives: Despite the huge burden of tobacco use or addiction, there has been a glaring scarcity of resources to tackle the problem. Although some of the tobacco users want to quit, very few have the opportunity to seek help from available treatment facilities. The study aimed to find out the profile of treatment seekers from clinic and community programs and also to compare the two groups. Method: This is a cross sectional, retrospective study of subjects enrolled in the clinic and various community outreach programs of a Tobacco Cessation Centre from the year 2002-2011. Modified intake form developed by the WHO was administered to the subjects. Results: Significant difference was found between the two groups with regard to the age of treatment seeking, education and socio economic status. Older subjects reported in greater numbers to the clinic, whereas younger subjects belonged to the community group. Community group had lower level of education, belonged to lower or upper lower socio economic status whereas clinic group had higher level of education and were from the middle or upper socio economic status. Curiosity (Z score = 3.2,P = 0.001) played a significant role in initiating the use in clinic group whereas role model (Z score = 5.1, P = <0.0001) and low self esteem (Z score = 2.0, P = 0.023) were significantly associated with community sample. Presence of medical complications (Z score = 12.5, P = <0.0001), awareness of physical harm of nicotine (Z score = 5.0, P = <0.0001) and awareness of addiction was significantly more in the clinic group. Interpretation and Conclusions: The difference in the socio-demographic and clinical profile of tobacco users in these two treatment groups is noteworthy, and is expected to offer useful information for the clinicians and as well as for the policy makers.
Keywords: Community, tobacco, treatment
|How to cite this article:|
Malhotra S, Ghosh A, Kakkar N. Profile of tobacco users amongst treatment seekers: A comparison between clinic and community sample. Indian J Soc Psychiatry 2017;33:327-35
|How to cite this URL:|
Malhotra S, Ghosh A, Kakkar N. Profile of tobacco users amongst treatment seekers: A comparison between clinic and community sample. Indian J Soc Psychiatry [serial online] 2017 [cited 2019 Aug 24];33:327-35. Available from: http://www.indjsp.org/text.asp?2017/33/4/327/218600
| Introduction|| |
Tobacco is the only legal consumer product that can harm everyone who are exposed to it and 50% of its users will eventually die of a tobacco related illness. India is second in the world in tobacco use, as out of 879 million tobacco users in the world, 31 % belong to India. Tobacco in India is used in many different forms in different regions. As per Global Adult Tobacco Survey (GATS) across 21 countries, 83 % of the world's smokeless tobacco users are in India. Additionally, in dual user's category, those who use both smoking and smokeless tobacco, India is at the second place. GATS, India (2009-10) reported tobacco use in any form was highest in 45-65 age group followed by 25-44 age group and was lowest in 15-24 age groups. This report also mentioned that tobacco use is more prevalent in rural areas than urban areas. In Indian males most common form of smoking is bidi (16%) followed by cigarette (10%). Among the smokeless tobacco Khaini is more commonly used (18%) followed by Gutkha (13%). Studies from India have reported that tobacco use in general, bidi and smokeless tobacco use in particular, is more common in people with low education and lower income., Moreover, this trend is similar in other countries as well as suggested by the WHO report., In a study in Sweden, over a period of 5-13 years of follow up 75% snus users remained stable over time and 2% switched to smoking and 20% quit tobacco. Although smokers were less consistent (54% continued with smoking), only 12% used snus at follow up. Therefore, the choice of using a particular type of tobacco appears to be some what stable longitudinally. The health hazards of tobacco use have been contributed and compounded by the low treatment seeking in the developing countries, including India. This perhaps can explain the low quit ratio in the sub-continent. On a comparative study, the quit ratio in the USA was observed to be 30%, whereas in India it was <5%., Recognizing the importance of tobacco cessation, 13 tobacco cessation clinics (TCCs) were started in 2002 by the Ministry of Health and Family Welfare, Government of India, and increased subsequently to 19. There is only one published study focusing on the clinic-demographic profile. This study was conducted in the TCC situated in the Chest Medicine Clinic in one of the tertiary care hospitals in Bangalore. This study consisted of 189 subjects attending the clinic over a 2 year period. A study with a larger sample spanning across wide range of time is needed for more reliable information regarding the clinic attending population. Another study had followed up the same cohort after 2 years and found that only 15% could be retained in the treatment. Moreover, the self reported point prevalence of abstinence was only 5%. This result points towards obvious lacunae in clinic based treatment. Study from Iran showed that smokers had asked for cessation help much more frequently from family and friends than from physicians. Limited number of tobacco users accessing these clinics and very low proportion of tobacco users from rural areas were the major disadvantages of these clinics. Understanding these caveats, community based interventions have been conducted and empirically validated in a study conducted in Mumbai. In this study, treatment retention and quit rate were 95.2% and 33.5% respectively, reiterating the importance of community based services. However, this study exclusively focused on the female subjects. It is intuitive to assume that the profile of tobacco users seeking treatment in the clinic and the community is distinctive. Therefore, an exploration into this area appears justified, which can further help in formulating suitable treatment strategies.
This study aims to see the profile and pattern of tobacco use among subjects' seeking treatment at Tobacco Cessation Centre and those attending the community outreach programs. The study would also compare the profile of tobacco users in the two groups.
| Material and Methods|| |
This is a retrospective case-record based study and was conducted at the Tobacco Cessation Centre (TCC) of a tertiary care institute in Northern India, which was established under the joint initiative of the World Health Organization (WHO) and Ministry of Health and Family Welfare of India in 2002. The services provided at the clinic includes, instance focus on tobacco cessation techniques through psycho-education, behavior counseling, habit modification skills, practical problem solving skills accompanied by some self-help tips for craving management and relapse prevention. Other than providing treatment in the clinic, the TCC also undertakes various community outreach programs and activities. The services were provided by two trained counselors specially appointed for the purpose of running the TCC. They worked under the active supervision and guidance of Prof. SM and were also monitored and assisted by Dr. AG.
This is a cross- sectional study of subjects enrolled in the clinic and its various outreach programs during the period of 2002-2011.
Total 2750 subjects were registered in the Clinic and 1423 were registered in the community outreach programs. No subjects were excluded from the study. They were included irrespective of their alcohol or drug use status. The community out-reach camps were conducted in various rural areas of Ropar and Mohali districts in the state of Punjab. Usually these areas are located within 25 KMs radius of the PGIMER, Chandigarh.
The subjects were administered the modified Tobacco Cessation Clinic - Intake Form developed by WHO. The information recorded in the intake form contains socio-demographic profile, and various aspects of tobacco use such as types of tobacco use, reason for starting, maintaining factors, cessation attempts, motivation, physical, and psychological health problems etc. During the treatment procedure, information obtained from subjects was kept confidential and documented carefully.
Chi-square test was administered for the comparison of various clinical and psychosocial variables between the clinic and community outreach groups. Post-hoc analysis was conducted and Z scores were calculated where ever applicable (3 × 3 or more contingency table). P values were calculated from the Z score. A Z score of more than 1.96 and a P value of less than 0.05 were taken as statistically significant.
Data for the study was generated as a part of WHO Tobacco Cessation Program and no additional assessment had been conducted as a part of this study. Thus, this study is a retrospective file based research and all the data were collected as a part of routine clinical assessment. A waiver for ethical clearance has been obtained from the Institute Ethics Committee.
| Results|| |
[Table 1] shows the type of tobacco used. Overall highest percentage of the sample comprised of smokers (53%). However, between the two groups, the clinic sample reported relatively higher percentage of smokers whereas community outreach group reported relatively higher percentage of smokeless tobacco users. The rural representation of the community sample was significantly more than the clinic sample. [Table 2] depicts the socio-demographic profile.
Significant difference was found between the two groups with regard to the age of treatment seeking. The Z scores revealed that in the clinic group more numbers of the subjects were in the higher age group of 45 years or above (Z = 4.3 p < 0.0001), and in the community outreach programs group more subjects were in younger age groups of ≤ 15 years (Z = 6.4 p < 0.0001). Also, there was significant difference among the two groups in education. Community out-reach group was found to have lower level of education, primary and up to high class (Z scores 21.2; p = < 0.0001, Z score = 2.9; p = <0.0001, respectively), whereas the clinic attending group was mostly graduate/postgraduates (Z scores 22.2). Significant differences emerged between the two groups in socio economic status. The subjects from lower socio economic status were significantly represented in the community sample (Z score = 17.1 p = <0.0001) whereas the representation of the middle or upper status was more in the clinic sample (Z score = 18.9 p = <0.0001).
Peer pressure was found to be the most common factor in initiating tobacco use in both the groups (X2 = 57.9). However, post hoc analysis shows that curiosity (Z scores = 3.2 p = 0.001) played a significant role in initiating the use in clinic group whereas role model (Z score = 5.1 p = <0.0001) and low self esteem (Z score 2.0 p = 0.023) were significantly associated with the community sample [Table 3]. Majority (75%) of subjects had never made any attempt to quit. But post hoc analysis revealed strong significant association of no attempt with community group (z score = 10.p = <0.0000 whereas multiple unsuccessful attempts Z score = 5.3 p = <0.0001) and one or more successful attempts (Z score = 7.9 p = <0.0001) were in clinic group. However, in community group awareness of physical harm of nicotine emerged as significant reason for quitting [Table 4]. Significant difference was found among the groups on stages of motivation. Post hoc analysis revealed that pre contemplators were more common in community group (Z score = 12.6; p = <0.0001), whereas most of the subjects seeking treatment in the clinics were either in the preparation (Z score = 12.5 p =<0.0001) or in action (Z score=6.0; p=<0.0001) stages of motivation. Significant differences were found for among the groups regarding reason for current consultation (X2 = 553.78). The presence of medical complications (Z score = 12.5; p = <0.0001), awareness of physical harm of nicotine (Z score = 5.0; p = <0.0001), and awareness of addiction defined the clinic attending group [Table 5].
Significant difference was found among the two groups in the type of smoking. In the clinic group cigarette smoking was reported more (Z score = 10.2 p = <0.0001) whereas community group was associated with bidi smoking (Z score = 15.5 p = <0.0001). The representation of dual users were also more in the clinic group (Z score = 7.1 p = <0.0001). In the clinic attending group, (Z score = 3.6; p = <0.0001) there were significantly more number of heavy smokers (>30 cigarettes/day). Although there was no difference with regard to the duration of smoking, in the clinic attending sample (Z score = 3.9; p = <0.0001) the duration of smokeless tobacco use was lesser (1-5 years). When other substance use was considered, clinic sample was observed to have significantly more use of alcohol, cannabis, opioids, benzodiazepines and others [Table 3].
| Discussion|| |
The present study consists of more than 4000 subjects and spans over a period of 10 years. It includes the treatment seeking tobacco users from the clinic and the community, providing comprehensive information. The large number, broad coverage, and use of an inclusive and relevant instrument for the assessment are likely to improve the impact and significance of this research.
In the clinic attending sample smoking tobacco users were over represented, whereas community outreach group had more smokeless tobacco (SLT) users. This observation is in line with the available evidence from India where studies from urban TCCs had demonstrated larger proportion of smokers., Another noteworthy finding in our study is the substantial proportion of dual users in both the groups. The figure (17%) lies in the range of (9.8%-26%) of the proportion of dual users in the community sample. In view of higher disease risks and greater difficulty in quitting, this group needs special attention for further research and intervention. Although majority of the subjects in both the samples fall in the age range of 16-45 years, older subjects (>45 years) and younger subjects (<15 years) are more common in the clinic and the community groups, respectively. A large proportion of the subjects in the TCC consulted various medico-surgical departments for their physical complaints and were referred from those clinics as their health problems were linked to tobacco. Because of the long incubation period between the initiation of tobacco use and development of a chronic disorder, people suffering from these disorders are likely to be older. This could explain the relatively higher proportion of older people using tobacco among the clinic based sample. Similar results were obtained from TCC located in the chest medicine clinics, where the mean age of attendees was 48 years. On one hand, higher proportion of young tobacco users in the community sample indicates the existence of problematic tobacco use in the child and adolescent population, while on the other hand, a smaller proportion of young subjects in both the groups points towards low treatment seeking in this highly vulnerable group. Nevertheless, it suggests an opportunity to target this population through community outreach. The male predominance in the entire sample is reflective of the general tobacco use pattern in India., However, significantly larger proportion of women in the community outreach indicates the importance of dissolving the barrier in treatment seeking to address the need of this special group. In the community sample, there were significantly more number of patients from the rural areas. This was self explanatory, as most of the camps were conducted in such areas. The study results also show that there were significant differences among the two groups in education and socio-economic status. In the clinic sample, more number of subjects had higher level of education and a larger proportion belonged to the middle or upper middle socio-economic status. Although we have not assessed the locality and distance from the clinic, higher socio-economic strata and educational qualification might indicate that the predominant group accessing treatment in the clinic are well- to- do urban population, who can afford the cost to travel the distance and spend the time required for the consultation. Therefore, an exclusive clinic based approach for tobacco cessation would leave out a major proportion of people who are in need and community based intervention could fill up the treatment gap.
Our study had shown peer pressure to be the commonest cause for initiating tobacco use. Other studies also suggest that it is not just the peer pressure but it's the bonding with peers and also the desire to be member of the group that serves for as factor for tobacco initiation and use., Curiosity as a factor for initiation was more common in the clinic attending subjects whereas having a role model and poor self-esteem for tobacco use was more common in the community sample. Although speculative, this observation might suggest distinctive personality profile between the two groups of tobacco users. Role model as an initiating factor could be handled by school or media based preventive interventions. Poor self esteem indirectly points towards lack of assertiveness, which can be addressed by school based resistance skill training. Withdrawal symptoms were reported to be the most common maintaining factor for both the groups. However, nature of work and low self esteem were significantly more commonly encountered maintaining factor in the community sample. In addition, work place atmosphere was found to be a significant trigger for the community sample. Both the aforementioned observations could be explained by the fact that community sample had more people from lower strata and they would be working in unorganized sector where restriction on tobacco use may be less rigorously implemented. Studies suggest that cues associated with tobacco are major reason for using tobacco and cues also hinder quitting. Workplace environment could be an important cue and resultantly a significant trigger for the community group. Another reason could be more number of people from this group are smokeless tobacco users and smokeless tobacco can be easily kept in mouth without any obstruction in the work or getting noticed by others.
The age of onset of initiation in both the samples was around 19 years. The risks of tobacco use are highest among those who start early and continue the use for a long period. The early age of initiation underscores the urgent need to intervene and protect this vulnerable group from falling prey to this addiction. Majority of the treatment seekers in both the settings were using tobacco for more than 10 years duration and the mean score in the Fagerstrom test for nicotine dependence (FTND) was >5 (with the major proportion of subjects scoring ≥5), indicating tobacco dependence. Number of very heavy smokers (>31 cigarettes/day) was significantly more amongst the clinic attendees. Therefore, it is quite apparent that people seek treatment at a later stage after the development of addiction. Preventive measures might be considered directed towards early detection and intervention. Community based intervention is one such possibility. Moreover, majority of the both group of treatment seekers did not make any attempts to quit in the past, which is anyway in line with the existing evidence from India. There could be several speculative reasons for the same, starting from poor motivation, low self esteem, lack of awareness of harms related to tobacco use, or scarcity of treatment services available. Couple of these if not all could be targeted by health planners and policy makers. Assessment of the stage of motivation revealed that the largest proportions of subjects were in the contemplation stage, that is, they were weighing the risk and benefit of continuing tobacco use. The role of a counselor or a clinician is extremely crucial at this stage and a simple intervention from their side could tilt the decisional balance towards the action stage. Significantly larger representation of subjects in the clinic attending group, who were in the action/preparation stage of motivation, defines their treatment seeking attitude. Moreover, the focus of intervention in this group should be relapse prevention. The most important cause for consultation in the clinic attendees was presence of medical/physical complications, which included chest related problems, cardiac problems, gastro-intestinal and problems related to oral health. The substantial majority of the clinic attending subjects was referred from other medical departments in which they sought consultation for their physical problems. Hence, this pattern of significantly more health problem in this group is quite understandable. However, the fact that most of these subjects were smoking tobacco heavily and for a long duration must also be kept in mind. All these might have, in the place, made them more vulnerable to developing physical disorders. Most of the subjects in the community sample were pre-contemplators. This underscores the importance of brief motivational interviewing for this group of population. The use of other substances was significantly more common in the clinic sample, which was expected, given the co-location of the TCC with the drug de-addiction and treatment centre.
Our study was cross-sectional and based on retrospective account of subjects. The possibility of recall bias and under reporting could not be ignored. Most of our subjects were middle aged men, which are otherwise quite expected in any clinic based sample. However, under-representation of women and children points to the importance of community based research to supplement the current results. Moreover, this is a descriptive study thus not intended to find any causal association for varied profile of tobacco users between clinic and community. Therefore, the differences in clinical characteristics might be mediated by differences in the socio-demography parameters like place of residence, education, and socio-economic status. However, the present study did not intend to explore this area.
Our study highlighted the importance of community outreach camps, in addition to the hospital based TCCs. The difference in the socio-demographic and clinical profile of tobacco users in these two treatment groups is noteworthy and is expected to offer useful information for the clinicians and well as for the policy makers. The relevance of this service is not only in terms of extending available treatment resources but also to provide a supplementary and tailor-made intervention for a distinctive profile of tobacco users.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]