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Study Protocol

The association of smokeless tobacco usage with the mental health status of late adolescents in rural areas of Wardha district: a cross-sectional study

[version 1; peer review: awaiting peer review]
PUBLISHED 18 Apr 2024
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REVIEWER STATUS AWAITING PEER REVIEW

This article is included in the Datta Meghe Institute of Higher Education and Research collection.

Abstract

Introduction

The unburned tobacco consumed orally is referred to as Smokeless tobacco. Smokeless tobacco consumption among rural adolescents is seen at a large scale. The early initiation of smokeless tobacco is associated with physical as well as psychological problems in human beings.

Objectives

This research aims to ascertain the frequency of smokeless tobacco utilization and investigate the association between the use of smokeless tobacco and mental health outcomes in late adolescents.

Methods

It is an analytical cross-sectional study that will be conducted in the rural field practice area of the Department of Community Medicine, JNMC, DMIHER (DU), Wardha district. The students aged 15 to 19 years from middle school, secondary, and higher secondary school will be the participants. The assessment of mental health status will be determined based on the score obtained from the Strengths and Difficulties Questionnaire (SDQ). The Chi-Square Test will be used to find the correlation between the variables. The data analysis will be presented via tables, graphs, and charts.

Study implications

This study will provide evidence for policy generation and strengthen the existing policies associated with smokeless tobacco usage among the adolescent population.

Keywords

Smokeless tobacco, mental health, late adolescent, tobacco usage, strengths and difficulties questionnaire

Introduction

India has one of the largest percentages of adolescents all over the world.1 Individuals falling within the age range of 10 to 19 years are characterized as adolescents. Adolescents were recently separated into two categories by the Lancet Commission: Early adolescence spans from 10 to 14 years, while late adolescence covers the age range of 15 to 19 years.2 Adolescence is a special time of development when numerous psychological, physical, and social changes occur.3 High rates of adolescent smoking continue to be a global public health problem despite the convincing evidence of smoking’s addictive qualities and the wide range of hazards associated with it.4 Because it was once believed that adolescents were less vulnerable than the rest of the population, adolescent health has been neglected.5 Major public health concerns include mental health issues, which are among the most significant causes of illness for children and adolescents worldwide.6

The term “Smokeless Tobacco” (SLT) is denoted as any unburned tobacco consumed orally or nasally. Smokeless Tobacco is generically categorized as “spit tobacco” or “chewing tobacco”.7 More than 300 million individuals use smokeless tobacco worldwide at this time while over 200 million smokeless tobacco users are there in India and Bangladesh. According to the World Health Organization (WHO), South East Asia is home to 90% of smokeless tobacco users.8,9 Addictions that start throughout childhood are probably going to last until adulthood. Adolescents today are exposed to a growing number of shifting lifestyles that harm their health. Parents and the community are clueless about how to handle these kinds of situations.10 According to the Global Adult Tobacco Survey-2 (GATS-2), the incidence of smokeless tobacco users in Maharashtra is reported to be 24.4%.11 In Rural Wardha, the adolescents mostly preferred to consume freshly prepared Kharra (mawa), gutkha, dry tobacco/and lime, dry snuff (nus), and paan which comes under the category of smokeless tobacco.10

As mentioned earlier adolescents are exposed to a variety of physical, emotional, and social changes, as well as exposure to risk factors, unfavorable settings, and altered lifestyles which eventually lead to mental health issues. There is a startling majority of approximately 253.2 million, or one-fifth, out of which 1.22 billion adolescents worldwide reside in India. Of them, 7.3% have a mental illness of some kind; the frequency is the same for men and women. A variety of factors, including parents’ occupations, peer pressure, academic pressure, expectations of great accomplishment, low socioeconomic status, and family environment, might exacerbate depression symptoms in adolescents. They often turn to tobacco usage as a coping mechanism for these issues, but this just serves to keep their mental health from getting worse.5

Rationale

Numerous research studies have explored the prevalence of mental health problems in various regions of India, with a particular emphasis on children and adolescents. Nevertheless, very few studies have looked at risk factors that could lead to mental health problems, like young teenagers who are still in school and their dangerous use of smokeless tobacco. Therefore, the purpose of this study is to assess the prevalence of smokeless tobacco use and the association of smokeless tobacco use with the mental health status of adolescents (aged 15 to 19) in the rural field practice area of the Department of Community Medicine, JNMC, DMIHER (DU), Wardha district.

Aim

Assessment of prevalence of smokeless tobacco and its association with the mental health status of late adolescents.

Objectives

  • 1. To assess the prevalence of smokeless tobacco among late adolescents.

  • 2. To assess the association of smokeless tobacco usage with the mental health status of late adolescents.

Methods

Study design

The present study will be analytical and cross-sectional.

Study setting

The research will take place in the rural field practice area affiliated with the Department of Community Medicine at JNMC, DMIHER (DU).

Study duration

The research will be conducted from October 2023 to June 2024.

In October 2023, the review of literature has been began, and as of right now, the IEC approval has been approved to carry out this study.

Study participants/population

Adolescent girls and boys aged 15 to 19 years from pre-universities from the rural area will be the study population.

Inclusion criteria

  • 1. The study participants will be late adolescents aged 15 to 19 years.

  • 2. The participants who are physically and mentally stable will be included in this study.

  • 3. Those who are willing will be included in this study and consent will be taken.

Exclusion criteria

  • 1. People below 15 years and above 19 years will be excluded from this study.

  • 2. The adolescents who are physically and mentally unstable will be excluded from this study.

Sample size

The sample size is calculated based on the Global Adult Tobacco Survey-2 factsheet Maharashtra, which was carried out in year 2016-17. According to Global Adult Tobacco Survey-2 factsheet Maharashtra, the prevalence of smokeless tobacco users was 24.4% in adults.11

By considering the above prevalence to calculate sample size and using the formula

N=4PQd2

P = Prevalence (24.4%)

Q = 100-p = 75.6%

d = margin of error (20% of p = 5)

Therefore,

N=4PQd2

N = 4 × 24.4 × 75.6/25

N = 281

So, the sample size is 281 for this study.

Sampling method

A systematic random sampling procedure will be used, where a list of all eligible late adolescents will be extracted from the pre-university, and the sampling fraction will be obtained by dividing the total population by sample size, which will be used as interval (n). The 1st number will be chosen randomly, and then every nth number after the 1st will be included as a study participant. The interview technique using the online tool Kobo Collect (https://www.kobotoolbox.org/) will be used. This will be done until the desired sample size is achieved.

Variables

Variables about mental health status and socio-demographic information will be examined in this study.

Demographic characteristics of the population that was selected include age, gender, parental education, parental occupation, and monthly family income.

Data collection tools

This study will utilize a questionnaire designed to capture socio-demographic factors. Additionally, it will incorporate established tools such as the Strengths and Difficulties Questionnaire (SDQ) and the Indian Adolescent Health Questionnaire (IAHQ), including their respective scoring mechanisms. The questionnaire is adapted from a previous research study conducted by Roy et al. in 2023, which served as a mother research article for this research.5 This survey will assist in determining the relationship between late adolescent mental health and smokeless tobacco usage. Variables, data sources, and method of data collection is shown in Table 1.

Table 1. Important study parameters, their variables, data source, and data collection method.

Key parametersVariablesData sourceData collection methods
Socio-demographic profile

  • - Name

  • - Age

  • - Sex

  • - Education

  • - Parents education

  • - Parents occupation

  • - Economic status

Adolescent boys and girls 15-19 yearsA survey using a questionnaire
Indian Adolescent Health Questionnaire and Strengths and Difficulties Questionnaire

  • - Duration of last tobacco use

  • - Main influencer for tobacco use

  • - Conduct

  • - Hyperactivity

  • - Emotional problems

  • - Peer problems

  • - Social behavior

Adolescent boys and girls 15-19 yearsA survey using a questionnaire

Data collection procedure

The study participants will be selected using a systematic random sampling method from pre-universities. To ensure that participants fully understood the research goals, the purpose of the study will be explained to them in their local language. The informed consent will be taken from the head of pre-university in written for carrying out the study. Similarly, in-depth interviews with randomly selected study participants will be conducted until the point of data saturation.

Bias

While collecting the data from study participants, recall bias can occur which may influence the results. The memory component of this study may have contributed to recall bias. We’ll lessen this bias by using a well-crafted, uncomplicated, and fundamental questionnaire.

Ethical consideration

The approval for carrying out the study has been received from the Institutional Ethical Committee of DMIHER (DU), Ref.No. DMIHER (DU)/IEC/2023/41 on dated 20/12/2023.

Consent: The informed consent will be taken from the Head of pre-universities in written for carrying out the study before including the study participants who will be of 15 to 19 age group. Confidentiality and privacy will be closely upheld during the entire investigation. There will be steps taken to reduce any possible hazards or harm to participants, including making recommendations for necessary medical consultations.

Data analysis

After the data is imported into Microsoft Excel, it will be examined using the statistics program R Statistical software (https://www.r-project.org/). We will determine the frequency and percentages of analytical statistics. The Chi-Square Test will be used to find the correlation between the variables. The data analysis will be presented via tables, graphs, and charts.

Study status

The study has not been started yet. The IEC approval has been approved to carry out the study.

Expected outcomes/Results

This study will evaluate the prevalence of smokeless tobacco use among late adolescents. Additionally, the relationship between late-adolescent mental health and smokeless tobacco use will be evaluated. This project will support multiple studies, including public awareness campaigns, education, and group discussions, to increase public awareness.

Discussion

According to Subba et al., in 2011, the use of smokeless tobacco is becoming more common in all of these countries, from developed ones like Bangladesh, India, and Nepal to highly industrialized ones like Sweden and Canada.8,12 In the book published by Rodgman and Perfetti in 2013, the most widely used smokeless tobacco goods in South Asian countries are Khaini, Gul, Pan Masala, and Zarda. The over 4,000 different compounds included in smokeless tobacco products, including nicotine, carcinogens, and other hazardous substances, are thought to have harmful consequences on health.13 The International Agency for Research on Cancer (IARC) has determined, based on publicly available epidemiological research data, that the use of smokeless tobacco products is associated with an increased risk of cancer in individuals.14

As per the case study conducted by N. Islam and M. Al-Khateeb in 1995, tobacco can be easily obtained at reasonable prices at any place. Even banned brands manage to get in through a variety of unapproved means. As a result, even in rural places, the rich and the poor can have cigarettes and other tobacco products delivered right to their door. Younger people are reluctant to engage in tobacco use in the presence of their parents or elders.15

In 2017, Huque et al. conducted a literature study and found that over 27% of adult Bangladeshis aged 15 years or older use smokeless tobacco in various ways. In South Asian nations, the most popular smokeless tobacco products include Zarda, Pan Masala, Gul, and Khaini. Age, gender, income level, and education are all associated with the usage of smokeless tobacco. It has been observed that the consumption of smokeless tobacco is linked to a higher risk of cardiac disease, stroke, and oral cancer.7

In a community-based research by Dongre et al., in 2008, adolescents in rural areas were found to consume tobacco products at a relatively high rate. Boys who are sociable and spend a lot of time with their companions are more susceptible to tobacco consumption due to peer pressure. Freshly made kharra, which was meant to be milder than gutka, is what they prefer to consume. To minimize the primary uptake of nicotine, especially smokeless tobacco among rural adolescents, a multifaceted community-based intervention plan that guarantees law enforcement and raises awareness among parents and schoolchildren about the negative impacts of tobacco intake is needed.10

According to Roy et al., in 2023, a favorable record of chewing tobacco or smoking cigarettes was the most important predictor of poor mental health. Two out of every three individuals with significant mental health disorders worldwide smoke currently, and as a result, they pass away roughly 15-20 years earlier.5 According to Caris et al., in 2003, there is a general positive correlation between adolescent school students’ tobacco use and behavioral issues.16

According to a fact sheet launched by the World Health Organization (WHO) in 2021, Tobacco usage and mental health have a complicated and enlightening relationship. Tobacco is listed as one of the leading causes of death for those who are suffering from serious mental health disorders, who typically pass away 15–20 years earlier than expected. Tobacco usage has an impact on not just death rates but also quality of life and coping mechanisms for mental health issues. For instance, smoking decreases the efficacy of some drugs used to treat mental health issues. It highlights the critical role that public health services play in supporting individuals with mental disorders for tobacco cessation. In addition to improving physical health, stopping can have several positive effects on mental health, including lowered stress, anxiety, and depressive levels, increased mood, and even fewer signs of attention deficit hyperactivity disorder (ADHD).17

Implication of study

The risk of unstable mental health status can be increased among late adolescents due to the high prevalence of consumption of smokeless tobacco. So, this study will provide evidence for policy generation and strengthen the existing policies associated with smokeless tobacco usage among the adolescent population. Ultimately one of the risk factors for lifestyle disease can be halted in the early stage of life and will build prevention and control of lifestyle diseases.

Limitations

Interviews will be used to gather data, which could have an impact on how accurate the findings are. The study can be influenced by recall bias, selection bias, measurement bias, and confounding factors, all of which may distort the results and compromise their validity and generalizability.

Dissemination

This study protocol will be presented at conferences and seminars and published in an indexed journal.

Ethics and consent

The approval for carrying out the study has been received from the Institutional Ethical Committee of DMIHER (DU), Ref.No. DMIHER (DU)/IEC/2023/41 on dated 10/12/2023.

Consent: The informed consent will be taken from the Head of pre-universities in written for carrying out the study before including the study participants who will be of 15 to 19 age group. Confidentiality and privacy will be closely upheld during the entire investigation. There will be steps taken to reduce any possible hazards or harm to participants, including making recommendations for necessary medical consultations.

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Dhage V and Nagtode DN. The association of smokeless tobacco usage with the mental health status of late adolescents in rural areas of Wardha district: a cross-sectional study [version 1; peer review: awaiting peer review]. F1000Research 2024, 13:293 (https://doi.org/10.12688/f1000research.147312.1)
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Comments on this article Comments (0)

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VERSION 1 PUBLISHED 18 Apr 2024
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Alongside their report, reviewers assign a status to the article:
Approved - the paper is scientifically sound in its current form and only minor, if any, improvements are suggested
Approved with reservations - A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit.
Not approved - fundamental flaws in the paper seriously undermine the findings and conclusions
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