This study was done to assess the prevalence of tobacco use and level of nicotine dependence in outreach program of BPKIHS-Dharan, Nepal. Tobacco prevalence in this study (32.8%) was found almost similar to the studies done by STEPS survey [13] in Nepal in 2013 (30.8%) and Sreeramareddy et al.[14] (2011) (30.3%) . Tobacco prevalence in male was found to be lower (42.8%) as compared to the studies done by STEPS survey [13] in Nepal in 2013, Sreeramareddy et al. [14] and NDHS-2016 [15] where it was found to be 48.1% , 56.5%, and 52.3% respectively. It may be due to the fact that various forms of tobacco (betel / betel quid (Paan) and water pipe) were not considered as it was considered in above studies. Tobacco prevalence in current study in female (20%) was found to be consistent with the studies done by Sreeramareddy et al. [14] (19.6%). However it was found higher than the studies done by STEPS survey [13]2013 and NDHS-2016 [16] where it was found to be 14.1% and 8.4% respectively.
The smoking tobacco pattern in this study was found to be lower as compared to the other studies done by STEPS survey [13] 2013, Sreeramareddy et al. [14] and NDHS-2016 [15] .This may be due to the fact that in this study prevalence of smoking, smokeless tobacco and both form were categorized differently whereas only smoking and smokeless form were categorized in other studies. The prevalence of smoking in male in current study was found to be lower with other studies [13-15] done in Nepal. The prevalence of smoking in female was found to be almost similar to NDHS 2016 [15] (6.2% vs 5.8%) whereas it was found to be higher in STEPS survey [13] 2013 (10.3%).
The prevalence of smokeless tobacco users was found to be similar to Sreeramareddy et al.[14] (14.3% vs 14.6%) whereas it was found to be lower as compared to STEPS survey [13] (17.8%). The use of smokeless tobacco was found to be low among male and high among female in our study as compared to other studies done by STEPS survey [13] 2013, Sreeramareddy et al. [14] and NDHS-2016 [15].The prevalence of smokeless tobacco users in female was found to be similar to Global Adult Tobacco Survey (GATS): India 2016-17 Report [16] (11.6% vs 12.8%). Higher prevalence of smokeless tobacco use in female in this study might be associated with lower level of education. Almost half of the female (47%) tobacco users in this study were illiterate and very few (8%) had secondary and higher level of education. The rate of smokeless tobacco was highest among the illiterate and lowest among those with a college education [17,18]. Dual (use of both smoking and smokeless tobacco) use of tobacco was almost similar to global Adult Tobacco Survey: India 2016-17 Report [16] (3.6% vs 3.4%).
Almost 45% tobacco users had positive family history of tobacco use. It had been shown that habit of tobacco use run in families [19].
More than half of the tobacco users (127, 53.4%) also consumed alcohol. Alcohol consumption was found to be more among male (102, 58.6%) than female (25, 39.1%). Study also confirmed that co-use of tobacco and alcohol [20]. Mean age of initiation of tobacco smoking was found to be almost similar (19.10± 5.939) to STEPS survey (18.2 years) [13].
About one in three (almost 29%) tobacco users used the first tobacco immediately or within five minutes of waking up which is in contrast to GATS: India 2016-17 Report [16]where about one in five (18%) daily tobacco users resorted to tobacco use immediately or within five minutes. This indicates that dependency of tobacco was high in our study population.
Almost 48% had medium and high level of nicotine dependency among smokers which is almost similar to the study done by Aryal et al. [12] where about 51% had medium and high level of nicotine dependency. However high level of nicotine dependency was found in only 9% as compared to 20.4% in Aryal et al [12].This study was conducted exclusively in a community level which comprises individuals from both rural and urban settings.
Till date no any study had been done in Nepal regarding nicotine assessment of smokeless tobacco users. In our study nicotine dependence was seen more in smokeless tobacco users (80%) as compared to smokers (48%). Higher median duration of use of ST in comparison to smoking (17years versus 11.5 years) may be one of the factor. Also, it may be due to that smokeless tobacco contains more nicotine as compared to cigarette smoking [21].
Only 24.24% (64) tried to quit tobacco at least 1 or 2 times in last one year. More percentage of male tobacco users (51, 26.4%) tried to quit in comparison to female (13, 18.3%). Evidence suggests that women were significantly less likely to quit smoking than men both due to biological and psychological factors, suggesting that the addictiveness of smoking may be greater for females [22].
The various factors for high level of nicotine dependency include: lower income, lower education, younger age of first smoking [23], high alcohol dependence [23,24], mood and anxiety disorders [25] and genetic factors [23,26]. High nicotine dependence is associated with lower quality of life, lower work productivity and higher health-care use [27]. Lower level of education, more duration of tobacco use, history of less previous quit attempt in last one year and elder females may be the factors associated with more nicotine dependency level seen in female in our study. Most of the studies were done considering only smoking form of tobacco whereas our study considered both form of tobacco i.e smoking and ST.
Strengths and Limitations of the study
First, social desirability bias [28] might have occurred. Social desirability bias refers to the tendency of respondents to give socially desirable responses instead of giving true responses. It becomes a major issue especially in socially sensitive issues such as politics, religion, and environment, or personal issues such as drug use, cheating, and smoking [29]. As the tobacco use status was obtained through self-report without biochemical verification, which might lead to reporting inaccuracy. There may be a possibility of information bias especially related to history of tobacco use and number of cigarettes/tobacco can or pouches used per day. However, Society for Research on Nicotine and Tobacco (SRNT) Subcommittee on Biochemical Verification [30] suggested that in population based studies biochemical verification is neither feasible nor necessary.
Second, the study was based on non-probability sampling (convenience sampling). The effect of outliers can be seen in this kind of subject selection. Outliers are cases whom consider as not belonging to the data [31]. Therefore the result shows associations but do not deliver evidence for causality.
Third, this study might hide the true prevalence as smoking by women is socially unacceptable. The cultural and geographical variation might affect tobacco use and level of nicotine dependence [32].
Although the convenience sampling was used, our study covered more than 30% of the districts of province number one. The data collection was done in various parts of the selected districts. Moreover the results obtained from this study can be generalized in province number one. Further studies are required to confirm the dependency using the bio-markers. A large nationwide study should be done to assess the level of nicotine dependence.
Recommendations
It is very important to develop a tobacco cessation program. The findings from our study could be a stepping stone for opening of tobacco cessation centers, which can help to reduce the tobacco prevalence as well mortality from oral and other cancer caused due to tobacco use. Health education (HE) can raise the awareness and motivate patients to think about quitting of tobacco use. HE along with nicotine replacement therapy (NRT) should be incorporated to reduce nicotine dependence as well as tobacco use prevalence. In outreach programs health education can impart knowledge about harmful effects of tobacco and raise awareness about quitting to the people in that area. Health education and other protective measures should be taken by government as well as health professionals that discourage tobacco use and help to people to quit tobacco which help to save more number of lives result from deadly consequences of tobacco use.