Tobacco use among adolescence: an Emerging pandemic by DR. LAKSHMI A

Posted on June 23, 2017 at 12:35 PM


Tobacco use kills nearly six million people worldwide each year. According to the World Health Organization (WHO) estimates, globally, there were 100 million premature deaths due to tobacco in the 20thcentury, and if the current trends of tobacco use continue, this number is expected to rise to 1 billion in the 21st century.

The World Bank has reported that nearly 82,000–99,000 children and adolescents all over the world begin smoking every day. About half of them would continue to smoke to adulthood and half of the adult smokers are expected to die prematurely due to smoking related diseases. If current smoking trends continue, tobacco will kill nearly 250 million of today's children.

Over one billion people globally smoke tobacco regularly. Tobacco use among adolescents is influenced by multiple etiological factors, including individual, socio-cultural and environmental factors38. Adolescent tobacco use is a complex behavior factors like, social bonding, social learning, lacking refusal skills, risk-taking attitudes and intentions have been highlighted as reasons for the onset of tobacco use in studies in developed countries.

Cigarette smoking, in the developed world, has been the major habit among children for both boys and girls. They usually take to the habit while in school before the age of 18. In India about 5 million children under the age of fifteen are addicted to tobacco. Early initial consumption of tobacco has been regarded as a serious health problem not only because it is believed to open the way for subsequent poly drug use, but also because of its linkage to impaired psychological and social development reflected in disrupted familial relations, school involvement and employment. According to WHO (2009) tobacco consumption, in India, will continue to increase at 2.4 percent per annum and most of the new users will be India's school children and those who begin to use in their mid-teens are likely to get lung cancer by the time they are in their mid - thirties. Further, tobacco use may also give these students hypertension, heart disease, recurrent lung infections, ear infections, asthma, cough and poor grading.

Patterns of Use

Tobacco is used in a wide variety of ways in India including smoking and smokeless use.

Smoking Practices

Tobacco is smoked in the forms of beedis and cigarettes or by using devices like hooka, hookli, chhutta, dhumti, or chillum. Smoking of cigars and pipes are not common in India, as they are in most western countries.

Cigarette smoking is common in urban areas. Both locally manufactured and imported brands of cigarettes are available. However, because of relatively higher cost of cigarettes as compared to other forms of tobacco, cigarette smoking is more common among the upper and middle socioeconomic classes than among the poor population.

Beedi is a cheap smoking stick, handmade by rolling a dried, rectangular piece of temburni leaf with 0.15–0.25 g of sun-dried, flaked tobacco filled into a conical shape and the roll is secured with a thread. The length of a beedi varies from 4.0–7.5 cm. Beedis are commercially available in small packets.

Hooka is an indigenous device, made out of wooden and metallic pipes, used for smoking tobacco. The tobacco smoke passes through water kept in a spherical receptacle, in which some aromatic substances may also be added. Hooka smoking is a common method of socializing among the village folk, especially in the Northern and Eastern parts of India, and is a part of the rural cultural life. Its use is more common among the adults and older generation. However, it is not popular among adolescents, because the adults generally discourage younger population from using hooka.

Hookli is a short clay pipe-like device, being about 7 cm long, and is used for smoking tobacco in some parts of the country.

Chhutta is a coarsely prepared roll of tobacco (cheroot), smoked with the burning end inside the mouth (reverse chhutta smoking). Its use is prevalent in coastal areas of the province of Andhra Pradesh in southeastern India.

Dhumti is a cigar-like product made by rolling tobacco leaves inside the leaf of jackfruit tree. Occasionally, dried leaf of a banana plant is used. Males smoke dhumti in conventional manner, whereas females smoke it in a reverse manner, i.e., keeping the burning end inside the mouth. Dhumti smoking is quite popular in the Goa province of the Western India.

Chillum is a conical clay-pipe of about 10 cm long. The narrow end is put inside the mouth, often wrapped in a wet cloth that acts as a filter. This is used to smoke tobacco alone or tobacco mixed with ganja (marijuana) in northern parts of the country.

Smokeless tobacco use

Tobacco is used in a number of smokeless forms in India, which include betel quid chewing, mishri, khaini, gutka, snuff, and as an ingredient of pan masala.

Betel quid is a combination of betel leaf, areca nut, slaked lime, tobacco, catechu and condiments according to individual preferences. Tobacco is an optional component. Its use is prevalent all over India. However, there are differences in the components used in different regions of India.

Khaini consists of roasted tobacco flakes mixed with slaked lime. This mixture is prepared by the user keeping the ingredients on the left palm and rubbing it with the right thumb. The prepared pinch is kept in the lower labial or buccal sulcus. Its use is common in eastern India.

Mawa is a mixture of areca nut, tobacco and slaked lime and is chewed. Its use is common in rural areas of Gujarat province. It is quite popular among the young population of ages 15–19.

Snuff is a black-brown powder obtained from tobacco through roasting and pulverization. Snuff is used via nasal insufflation and is popular in eastern parts of the country. It is also applied on the gum by finger (this practice is usually initiated as a dentifrice) in the Western India, where it is known as bajar and mishri.

Gutka is a manufactured smokeless tobacco product (MSTP), a mixture of areca nut, tobacco and some condiments, marketed in different flavors in colorful pouches.

Pan masala is a betel quid mixture, which contains areca nut and some condiments, but may or may not contain tobacco. The mixture is chewed and sucked. Unlike cigarettes, tax levied on pan masala is low. Low cost and not being associated with smoke have led to an enormous increase in the use of all types of areca nut and smokeless tobacco among the Indian population including adolescents. It has also been promoted as a "post meal mouth freshener", making it quite popular. Initially, it was more popular in the Northern India, but with a massive advertising, it is now being used all over the country. Pan masala is as harmful as smoking, although the nature of harmful effects are different. Its use has been associated with high risk of oral cancer and submucus fibrosis in mouth, which also has a high potential for cancer development. It is made by the use of waste tobacco, mid-ribs of tobacco leaves and floor sweepings from cigarette factories. It is available in the forms of small packets and cans, sold at affordable prices with attractive, shiny colored wrappings.

Beedis, khaini, and mishri are commonly used in rural areas and cigarettes are mainly used in urban areas. Pan masala was initially popular in the urban segment only, but over the last few years, it has been consumed in rural areas as well.

According to the most recent Government of India's National Sample Survey data, there are 184 million tobacco consumers in India. About 40% of them use smokeless tobacco, 20% consume cigarettes, and another 40% smoke beedis. Smokeless tobacco use includes pan masala and chewing of tobacco in different forms. Tobacco is also smoked using indigenous devices like hooka, chhutta or dhumti in different parts of the country [20]. Thus, in contrast to the other parts of the world, tobacco is used in a variety of ways in India, which include smoking and smokeless tobacco use.

Stages of Development of addiction

The initiation and development of tobacco use among children and adolescents progresses in stages:
1. Forming Attitudes and Beliefs about Tobacco
2. Trying Tobacco
3. Experimenting with Tobacco
4. Regularly Using Tobacco
5. Becoming Addicted to Tobacco

This process generally takes about 3 years.

Psychosocial Factors Leading to Initiation of Tobacco Use
A number of factors influence the use of tobacco by children and teenagers. Some of these are the family history of tobacco use by elders, peer influence, experimentation, easy access to such products, personality factors, underlying emotional and psychological problems, accompanied risk-taking behaviors, and most importantly, the aggressive marketing strategies of the tobacco industry.

The role of family
Family plays a very important role in initiation of tobacco use by a young child or adolescent. Tobacco use by parents or an elder sibling increases the likelihood that a child begins smoking. As an example, many Indian fathers and grandfathers frequently ask the boys to fetch beedis or cigarettes from a nearby shop or kiosk. By this way, children are often introduced to such products at their very early life stages. A child growing in such a family watching his elder brother, father, uncles or grandfather using tobacco may perceive it as a family tradition that is to be followed. On the other hand, it is interesting to know that as an Indian tradition, younger individuals are not expected to smoke in the presence of elderly, because smoking by a younger person is taken as in contempt of the older people. Therefore, it is a paradox that the same elderly people, who passively show the way to smoke, are prohibitive of the same behavior by the younger generation in their own presence. However, this value system does not apply to the use of smokeless tobacco products.

The role of peer influence
Although children may start smoking for psychosocial reasons like peer influences, curiosity, desire for experimentation or as a remedy for stress, the pharmacological motives take on place very early in their smoking career. Consequently, by the time children smoke on a daily basis, they take up the same amount of nicotine from each cigarette as their adult counterparts do.

Peer pressure is an important determining factor for initiation of tobacco use among children and adolescents. There are several processes by which being associated with drug-using peers contributes to drug-abusing behavior. Here, modeling and social approval play an important role. When one is distressed due to any reason, an offered cigarette or beedi by a friend initiates the conforming process with a tobacco-using peer-group network.

Easy availability of tobacco products
Tobacco products are socially sanctioned but are freely available in every nook and corner throughout the country. Beedis are a bit cheaper than the cigarettes and hence are preferred by the poor who cannot afford cigarettes. The newly introduced MSTP are also cheaper than cigarettes and do not carry the trouble of lighting, and therefore, are more convenient to use, which makes it popular among the users..

Psychological/emotional factors
Poor school performance, truancy, low aspiration for future success, and school dropouts have been found to be associated with smoking at an early age]. Children and adolescents with anxiety and depression are likely to use tobacco and other drugs, as these have anxiety relieving and mood elevating properties. Furthermore, such children may socially be anxious and feel isolated in a company of peer groups. Initiation of smoking helps them to identify with the group and hence reduces social anxiety. Children with low self-esteem are likely to be vulnerable to drug use including the tobacco. As smoking behavior is associated with maturity and adulthood, tobacco use may serve to promote self-esteem..

Preventive Strategies
Considering the enormous adverse health consequences accompanying tobacco addiction, it is very important to develop preventive strategies to reduce tobacco consumption. Preventive strategies especially focused towards children and adolescents need to be initiated on emergent basis. This is more important for the developing countries like India, which have become the main targets of advertisement and promotional propaganda of various multinational tobacco companies .Preventive approaches include spreading awareness about the actual hazards of tobacco in the community especially among the vulnerable children and adolescents, curbs on advertisement and promotional campaigns, early identification of the users and providing treatment

Early Education
The benefits of early educational programs have been well reported for school children Such programs should not only focus on the harms caused by cigarette smoking but also on those caused by other forms of tobacco use like smoking hooka and beedis, and by the smokeless forms like gutka. In fact, a majority of Indian people are not aware of the health consequences caused by smokeless tobacco products. Added to this, a wrong belief is being spread throughout the country that beedis are less harmful than cigarettes. Some indirect promotional efforts even spread an untruth about some beneficial effects of beedis such as being abdominal gas and constipation reliever! Thus, in a country like India, widespread community awareness program on the hazards of local and cheaper tobacco products like beedis and gutka are more essential than few school based programs.

Curb on media advertisements and tobacco promotion
A very important step in primary prevention is the revamp of the existing tobacco policies of the government. The Government of India has recently taken some important legal measures, but there are still many problems in the enforcement of tobacco related law. Restrictions have been imposed on sales and on tobacco use in public places like railway stations, airports, hospitals and governmental offices. However, the more important aspect would be the strict observation and control of such restrictions. The sales of all tobacco and their easy access strongly need to be banned for children and adolescents. An initiative in this regard has been taken by stopping tobacco sale in vicinity of schools. We need to impose age restrictions in purchase of tobacco products. Stopping sales of tobacco to children is an important step towards reducing the number of tobacco users among the new generation.

Overall community development
The limitations of the long-term success of the school-based interventions have led researches to advocate approaches involving the creation of a wide social environment supportive of nonsmoking. This is extremely relevant to Indian societies, where economic disparity, unemployment, illiteracy and homelessness have been associated with all kinds of addictive behavior including the tobacco use by children.

A smart tobacco guide. by NIMHANS,Bangalore
Manual For Tobacco Control And Cessation For Health Professionals by WHO-Tobacco Cessation Centre,Cancer Institute(WIA),Adyar,Chennai.
Tobacco Use among School Children in Chennai City, by Kumar M., Poorni S and Ramachandran S.

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