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

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

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.