Knowledge, Attitude and Behavior Regarding the Hazards of Tobacco Use and Cigarette and Other Tobacco Products Act among Parents Visiting Pediatric Dental Clinic: A Cross- sectional Questionnaire Survey

DISCUSSION

Adolescents are conjugator of childhood and adulthood as they are motivated to experiment in all spheres of life to expand their capacity of autonomous decision making on major factors of life. Factors that influence and encourage adolescents to pick-up these destructive habits at a very young age should be taken into consideration, because there is not only biologic, cognitive, emotional, and social development of an adolescent during the developmental era but also the relationships to family, culture, and society as a whole. These habits have deleterious effect on overall well-being of adolescent which can hamper them to bloom to their full potential. Hence, children from the age group of 10 to 16 years were involved in our study.

Children are backbone of a Nation on their health and prosperity depends the progress of a nation.⁵ Children are like wet cement whatever falls on them makes an impression hence good habits formed in adolescents makes a great difference in adulthood.⁶ Therefore education is not only a tool for development of an individual, community, or a nation but a foundation of our future.⁷

Wright in 1975 gave the "Pedodontics Treatment Triangle" in which the child is at the apex of the triangle and the dentist and parents are at the base. The child is the focus of attention and all the efforts are toward providing a better oral health care to the child and to prevent them from acquiring tobacco habits by creating awareness in both parents and children. The arrows in the triangle indicate that the relationship between the three corners of the triangle are reciprocal hence knowledge, attitudes, and behavior can also be reciprocated. The target sample size of 400 of parent population was met by distribution of sociodemographic characteristic among the parents age group ranging from 28 to 64 in both the genders, where males dominated by 62.5% and females by 37.5%. Literature has a very few studies done on parents to assess the knowledge, attitude, and behavior of adolescents bringing out the uniqueness of this study.

India has a wide variety of smoking tobacco products like cigarettes, beedies, hookah, hookli, chutta, dhumti, chillum, and smokeless tobacco products like khaini, mawa, snuff, gutka, panmasala, etc. The most common hazardous substance used in India is tobacco as it is legally available, widely consumed and heavily promoted.⁸

The most common smoking product known to the parent population in our study is cigarette and beedis because of the easy availability and wide use in the urban areas of Bangalore. Chutta, dhumti, and chillum were least known and statistically significant because of the nonavailability of the product in the urban areas. Hookah and hookli was known in moderation as its use of prevalence is high in eastern countries (Table 1). Chhabra SK et al. also conducted a similar study in which cigarette smoking was most common smoking product used in the higher income groups as they use filtered cigarettes and in contrast, the lower and middle-income groups who were illiterates and less educated beedi smoking was found to be common.⁹ A study conducted by Narayan et al. similarly stated that Delhi urban population smoked cigarette commonly than beedies.¹⁰ In contrast, Kumar et al. concluded that beedis are the most common form of tobacco used because of the pricing strategy as beedis cost less than cigarettes.¹¹ The most common type of smokeless tobacco product known to the parent population was pan masala and gutka again due the easy availability and wide use in urban areas, mawa and snuff were least known due to their rare use as they are crude forms of tobacco used in remote villages of north India (Table 1). In a similar study conducted by Sinor PN et al. mawa was the most common product known which is in contrast to our results.¹² Among the smokeless tobacco form khaini and gutka which was statistically significant in our study, Sinha DN et al. conducted another study among medical and dental students that also revealed high levels of smokeless tobacco forms used were khaini and gutka.¹³

Smoking tobacco is also associated with major cancer all over the body including respiratory tract, gastrointestinal tract, cardiovascular diseases, liver, pancreas, kidney, urinary bladder, oral cavity, nasal cavity, cervix, etc.¹⁰ The major cause of cancer in the oral cavity is smokeless tobacco, risk of developing cancer increases with duration of use of tobacco, number and degree of inhalation. A total of 4% of all cancers in women 25% of all cancers in men and in developed countries it is about 16% in both sexes and in less developed countries it is about 10% overall. In recent studies, it has shown to cause renal and mental disorders as well.^14,15,16

In our study among the various health hazards, cancer was the most common health hazard known to parent population followed by lung and heart diseases, kidney diseases, and impact on mental illness was the least known by the parents (Table 2). Research evidence of the diseases has created awareness about the knowledge of the health hazards but the awareness about kidney and mental diseases have not yet caught much attention of public as little light has been thrown on its effects. Hence, creating awareness about it is essential. Ramadas K et al. conducted a study which had similar results as our study where cancer was the most common health hazard known to the participants.¹⁷ In contrast, Evins AE et al. concluded that smoking has been associated with a range of mental disorders including schizophrenia, anxiety disorders, and depression. People with mental illness have high rates of morbidity and mortality from smoking-related illnesses such as cardiovascular disease, respiratory diseases, and cancer.¹⁸ S Fareeda Begum et al. found decreased levels of total proteins in kidney diseases leading to renal glomeruli albuminuria and significant amount of globulins was present in urine of gutkha (27.40%) and khaini (28.88%) users.¹⁹ Magidson JF et al. concluded that smoking causes psychiatric disorders such as attention deficit, conduct disorder, depression, anxiety, mood swings, and alcohol or illicit drug dependencies.²⁰

India has one of the highest rates of oral cancer in the world, with over 50% attributed towards smokeless tobacco use.²¹ The incidence of oral cancer is highest in Asian countries like India, Sri Lanka, Pakistan, and Taiwan.²² Wani et al. reported a significant number of oral cancer patients in Agra, Allahabad, Manipur, Varanasi, and Moradabad belt of Uttar Pradesh in north India.²³ Balaram et al. conducted a survey in Chennai, Trivandrum, and Bangalore in southern India where the incident cases of cancer of the oral cavity were identified in three south Indian centers.²⁴ Pan chewing is one of the most important cause of oral cancer in either gender. Among men, however, 35% of cases can be accountable for smoking and alcohol drinking where it may play a synergistic effect as well. The tissue of the lips are the most common site for development of oral cancer. It may also involve the tongue, floor of the mouth, cheek lining, gingiva, palatal roof of the mouth and tend to spread rapidly.²⁵ A precancerous condition known as Oral submucous fibrosis (OSF) is caused by the use of areca nut in various forms of tobacco. Ranganathan K et al. published reports on areca nut use and OSF from Chennai, south India in which there was tightening of the inner cheek.²² Leukoplakia is also most common premalignant lesion of the oral cavity which causes white patches in the oral mucosa. It is scientifically proved that tobacco is the main culprit.

Among the harmful effects of using tobacco in the mouth, a nonhealing lump in the mouth was known to parents, followed by white patch in the mouth, difficulty in chewing, and swallowing food, but only few parents knew about the tightening of inner cheeks in the present study (Table 3). There is evidence of lack of knowledge in parents regarding the precancerous lesions like tightening of the inner cheeks and white patch which may be the precursors of cancers in the mouth. They are aware of the advanced symptoms but not the early symptoms this is largely reflected by the fact that most cases are in advanced stages when diagnosed even though there is a way when it can be diagnosed early during regular examination.

India is a signatory to Framework Convention on Tobacco Control since September 2003. Indian parliament has passed COTPA in 2003 to prohibit advertisement of tobacco and to provide for regulation of trade and commerce in the production of tobacco.²⁶ COTPA is the principal law governing tobacco control in India which includes prohibition of smoking in public places, within 100 yards of all EIs, sale to and by minors, mandatory display of pictorial health warning. A continual effort has to be made to increase the awareness of the act amongst the adolescents.²⁷

Prohibition of smoking in public places and mandatory display of pictorial health warnings on tobacco product packages was statistically significant in our study. They were also aware about prohibition of sale of products within 100 yards of all EIs, prohibition of sale of tobacco products to and by minors. The testing of all tobacco products for tar and nicotine content was least known which is also statistically significant (Fig. 1).

Goel et al. found a very high compliance rate of 92.3% for COTPA in a district of north India was better in health-care facility and EI and was worse in bus stands, railway station, and markets in his study.²⁸ Pimple et al. in their cohort study reported that only 28.2% EI displayed such a board at a noticeable place outside the institution.

The parents were not aware of the penalty for violation of COTPA law because of the poor implementation of the law. The penalty amounts are Rs. 200,Rs. 5,000, Rs. 10,000, Rs. Fine + imprisonment (Fig. 1). In similar studies conducted by Chaudhry et al., they found that the most common violation of point of sale was the advertisement boards that were larger in size than permitted by law.^29,30 In another study conducted by Pimple et al., they noted that there was only 25.2% compliance for display of health warning boards at the point of sale and nearly tobacco vendors. In a study conducted by Goel et al., they found that more than 25% were violating COTPA.²⁷ In the light of the existing evidence and the results of the present study, it is clear that the tobacco control policy in India is not geared adequately towards addressing the issue.

Attitude is a settled way of thinking and feeling about some concepts. A number of factors influence the use of tobacco by children and teenagers. Some of these may be family history of tobacco use, peer influence, experimentation, easy access to such products, underlying emotional, and psychological problems.

A Shah et al. suggests that early detection, moral, social, and psychological support for the adolescent victims who are already in the clutches of tobacco can be beneficial to support them to overcome the habit.² About 52.3% parents have the attitude that inculcating strong principles will help adolescents to overcome and to reject these habits which is statistically significant in our study. Early detection was opted by 26.4% and providing moral, social, and psychological support can support the victims was opted by 41.2%.Very few about 22.9% agree that de-addiction centers may also provide help for the victims (Fig. 2). Attitude of parents regarding the strict implementation of COTPA law, 13.6% of parents are not sure of strict implementation of COTPA law. A total of 18.8% agree for strict implementation of COTPA law, 61.8% of parents strongly agree for strict implementation of COTPA law in India, only 2% disagree for it. Hence, parents have a positive attitude towards implementation of COTPA law for the good of the society.

Behavior is the sequence of actions and mannerisms made by an individual in conjunction with their environment. The behavior of parents, friends, and celebrities can also influence the behavior of children to initiate smoking habits. In the present study, friends behavior influences much by 33.6% which is statistically significant, followed by the influence of celebrities by 11.8% and parents by 10.3%. The behavior of parents regarding the COTPA Law can bring about behavioral changes in children as well. In the present study, 83.2% of parents would like to quit smoking which is statistically significant. Most of the parents were motivated with a positive behavior by knowing the health hazards on them and their children to quit the habit. About 10% of parents sent their children to purchase tobacco products for them but recognized the danger of introducing tobacco products to the young ones and desired to modify their behavior. About 93.2% agree that tobacco products are harmful to health and would like to stay away from the tobacco monster. About 73.7% have educated their children regarding the hazards of tobacco products and COTPA Law and the rest were motivated to educate their children regarding tobacco products, their health hazards to prevent children from initiating the habits, and COTPA Law to help them to be better citizens of the country.