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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 54-58

Current trends in consumption of smokeless tobacco products among women in selected rural areas - A cross-sectional study

1 Department of Periodontics, Ahmedabad Dental College and Hospitals, Ahmedabad, Gujarat, India
2 Private Practitioner, Ahmedabad, Gujarat, India
3 Department of Orthodontics, Ahmedabad Dental College and Hospitals, Ahmedabad, Gujarat, India
4 Department of Periodontology, Himachal Dental College, Himachal Pradesh, India
5 Department of Dentistry, M L N Medical College, Allahabad, Uttar Pradesh, India
6 Department of Dentistry, Autonomous State Medical College, Mirzapur, Uttar Pradesh, India

Date of Submission14-Jul-2021
Date of Acceptance07-Dec-2021
Date of Web Publication29-Dec-2021

Correspondence Address:
Dr. Nirma Yadav
Department of Dentistry, Autonomous State Medical College, Mirzapur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sidj.sidj_11_21

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Purpose: The aim of this cross-sectional analytical study was to evaluate the impact of smokeless tobacco (SLT) products' consumption on women's health in the selected rural areas.
Methods: It was a cross-sectional rural-field area-based study in which randomly selected 500 women were asked to participate, out of which 205 women (who have completed 27 years of age with two pregnancies in life time) were selected and given a self-administered pretested in propria persona questionnaire using an objective sampling technique in 3 months. Statistical Package for the Social Sciences version-22 was used to analyze the data presented in a graphical and tabular format.
Results: Among the 205 respondents, majority (73.17%) were homemakers, while 26.35% were service holders. According to the findings, SLT with betel quid has been used by 52.6% of rural women for more than 5 years. In addition, during the past 5 years, 36.6%, 48.4%, and 38.8% of SLT used tobacco zarda, plain tobacco, and khaini. 40% of the respondents said that they use SLT for the pleasure of it. There was a significant association between occupation and regular use of SLT (P < 0.05).
Conclusion: Finally, despite the severe effects and consequences of using SLT, the general people, particularly women in rural areas, are unaware of its negative consequences, and its use remains unrestricted today, which is unfortunate. Approximately 63% of users were homemakers, according to this cross-sectional survey. To limit the use of SLT, a very robust comprehensive monitoring and evaluation system must be implemented at both national and international levels. Finally, it was discovered that rural women predominantly use SLT made from betel leaves, which is hazardous to both general and oral health.

Keywords: Betel quid, khaini, oral, smokeless tobacco, zarda

How to cite this article:
Agrawal C, Patel BA, Patel M, Sharma P, Fanda K, Kumar A, Yadav N. Current trends in consumption of smokeless tobacco products among women in selected rural areas - A cross-sectional study. Saint Int Dent J 2021;5:54-8

How to cite this URL:
Agrawal C, Patel BA, Patel M, Sharma P, Fanda K, Kumar A, Yadav N. Current trends in consumption of smokeless tobacco products among women in selected rural areas - A cross-sectional study. Saint Int Dent J [serial online] 2021 [cited 2022 Jun 29];5:54-8. Available from: https://www.sidj.org/text.asp?2021/5/2/54/334153

  Introduction Top

Despite the substantial scientific evidence that most of these products contain high nicotine levels and have various adverse side effects, tobacco smoking is becoming a prominent part of both younger and older generations' lifestyles.[1] In addition, India is the second largest consumer of tobacco despite smoking tobacco, and smokeless tobacco (SLT) use is linked to various oral mucosal abnormalities, including oral cancer.[2],[3]

The number of deaths due to SLT has increased rapidly globally; hence, even today, the use of SLT is one of the most severe health concerns facing humanity. In developing countries, buoyant oral cancer may be more prevalent due to cultural habits of chewing tobacco without smokes, such as the loose-leaf, sadagura, snuff, gull, and tobacco zarda, although the health effects of these social habits are not well known to the vast majority of low socioeconomic or rural people. SLT is strongly associated with periodontal tissue destruction and is considered a risk factor for periodontitis, tooth loss, hypertension, elevated serum cholesterol, coronary heart diseases, stroke, lung cancer, and gangrene. All of the factors mentioned above increase the cost of the family environment, causing constraints on the national level and that of the community.[4]

The prevalence and link between cigarette use and ever utilising SLT products were revealed in a 2015 survey done in Chennai, Delhi, and Karachi. Overall, 51.8 percent of respondents were female, and 61.6 percent were under 45 years old, and 52.6 percent, 36.6 percent, and 48.4 percent of individuals used SLT in this study, respectively.[5] The use of SLT in any form or disguise is fatal. Scientific evidence has clearly established that exposure to tobacco smoke can lead to acute and chronic disease, disability, and even death in extreme cases. According to a school-based 2020 cross-sectional study done in the United States, 22.5% of female high school students and 6.8% of female middle school students smoke and use tobacco products.[6] It is also important to note that – in comparison with the extensive research linking smoking with adverse health outcomes – evidence on the health effects of SLT is far less comprehensive. Information on dose–response relationships, prevalence estimates, and confounding variables is often sparse, while the novelty may not allow to fully understand the long-term risks of some products. As the use of SLT is culturally accepted in low socioeconomic countries and developing countries, culturally appropriate public awareness program is required to curb SLT use along with increased tax, pricing, enforcement of tobacco control laws, and cessation services.[6] The main purpose of the study was to find out the impact of SLT use among the women's health in the selected rural areas.

  Methods Top

This is a cross-sectional study on the awareness and consumption of SLT use and its ill effects among women in selected rural areas. For this survey, the population of rural areas was deliberately selected so as to have a good number from which to collect the data because of the time constraints of this study. Due to time constraints and limited facilities, this time-limited study and its sample size were not very large. The sample size was 205 women living in rural parts selected through a purposive sampling technique. It took approximately 2 h to complete the questionnaire, which had a final sample of 205 women and a translator for the illiterate women. Respondents who claimed they use SLT every day and had two pregnancies were questioned their demographics, living conditions, education, and employment as well as use of SLT during the COVID-19 lockdown. Inclusion criteria were women who voluntarily responded to the survey and consumed and used only one form of SLT, resided in rural regions, and had two pregnancies, irrespective of age.

Exclusion criteria were women with more than 2 pregnancies, who have consumed more than two products, and using any form of smoking tobacco products. A structured questionnaire was developed based on the purpose, content, and variables of the study. Before developing the primary data collection, an in-depth literature review was conducted. It was finalized in English after the questionnaire was revised and corrected based on the pretense findings. Information was collected through a structured questionnaire and face-to-face interviews with respondents. The purpose of the study was explained before filling out the questionnaire. The investigator cleans and edits the obtained data, and the data were manually processed, tabulated, and evaluated based on the purpose and objectives of the study. Data were analyzed using the IBM SPSS Statistical Package, version 22.0 (IBM Corporation, Armonk, NY, USA). The result was calculated with the help of Chi-square (χ2 test). The data were presented in the analyzed tubular forms, and tables and graphs followed the interpretation of the results.

Measurement of outcome variables

Current consumption was defined as consuming SLT products at least one time per day. We included respondents who were educated, could read Hindi and English questionnaires, had used SLT products for at least 5 years or more, and asked them to state which SLT products they had used.

  Results Top

[Table 1] shows distribution of the respondents by their occupation, whereas out of 205 respondents, maximum 73.17% were homemakers and 26.53% were service holders. On the other hand, employed women and day laborer represent very close to each other; those were subsequently 12.16% and 14.63%.
Table 1: Distribution of the respondents by their occupation (n=205)

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[Table 2] shows the distribution of responders by type of SLT product use (i.e., with betel nut, plain tobacco, tobacco zarda, khaini), with plain tobacco accounting for 48.4%, tobacco zarda for 36.6%, tobacco Areca quid for 52.6%, and khaini accounting for 38.8%.
Table 2: Distribution of the respondents by types of using smokeless tobacco

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[Table 3] reveals that the reasons behind using SLT were stated as for pleasure by 50.73% respondents, as addiction or habituation by 23.90%, as relief from toothache by 12.69%, and as relief from tiredness and relief from stress by 6.83%.
Table 3: Distribution of the respondents by rationale for using smokeless tobacco (n=205)

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[Table 4] shows that out of 205 respondents, almost 67.32% think that SLT products do not cause any harm in the oral cavity while only 32.2% stated that SLT products cause harm in the oral cavity.
Table 4: Distribution of the respondent's opinion cause of any harm in the oral cavity by smokeless tobacco use (n=205)

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[Table 5] depicts the association between respondents' work and their usage of various SLT products. Betel leaves are regularly used by 27.15 percent of housewives with or without tobacco, and 18.85 percent of the other group. The study results show that there was significant association between occupation and regular use of SLT.
Table 5: Relationship between use of various forms of smokeless tobacco (n=205)

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  Discussion Top

Since the selected area was a densely populated and congested rural area and with limited facilities, they were not able to give adequate priority regarding their improvement in socioeconomic status. Of the 205 respondents by profession, 73.17% were homemakers, 9.76% were self-employed women, 14.63% were daily wage workers, and only 2.44% were government service holders. SLT use among women was higher in low-income countries, according to a 2018 study by Kurlikar, and SLT use among married women is nearly identical to the findings of this study and 2018 data.[7] A study on prevalence of tobacco consumption habits in the United States in 2005 and 2010 done on working male adults aged 25–44 years showed that SLT consumption habits were highly prevalent in mining industries.[8] In this study, we found that out of 105 respondents, the reasons behind using SLT were stated as for pleasure by 40.0% respondents, as dependency or habituation by 37.1%, as relief from toothache by 19.0%, and as relief from tiredness and stress by 1.9%.

The findings of this investigation differed from those of Hussain et al.[9] and Egbor et al.[10] In terms of the prevalence of tobacco use habits among rural people in selected areas, it was discovered that about 20% of the respondents were business women, while 23.90 percent used smokeless tobacco products as a regular habit in our study, while 28.7% were due to family influence, 50.73 percent used for pleasure [Table 3], and 20.5 percent started out of curiosity.[10] The rural nature of African community may be the reason for the high prevalence of SLT products use and it was found that more than half of the respondents have been using SLT for 6–10 years and approx three quarters of respondents said they were unaware of the hazardous effects of using smokeless tobacco products (67.32%).[6],[11],[12]

According to the findings of this study, people living in rural areas are culturally and conventionally accustomed to use SLT, whereas it was difficult for those women living in other urban and semi-urban areas. Above finding is similar to the study conducted by Ahmed et al. Out of 719 students, 22% were current smokers and the rest 78% were nonsmokers. Half of the students reportedly mentioned that they started smoking due to peer pressure followed by curiosity (34%) to avoid anxiety and tension (28%), feeling of maturity (14%), symbol of manliness (9%), and unhappy family environment (8.2%), However, 24.5% of the respondents mentioned that they started smoking without any reason.[13] In this study, according to the type of SLT use, 45.3% used zarda, 10.5% used gul, 17.1% used sadapata, and 27.2% used khaini. About 38.7% of respondents were using sadapata five times and above per day. About 48.4% of respondents were using sadapata for more than 10 years. The study conducted by Mahiuddin. A study on tobacco consumption habits among the workers of a bidi (bin) factory in Bangladesh revealed that out of 275 workers interviewed, 74.55% were found to be as tobacco consumers. Among them, 86.83% were smoked biri/cigarette. 40% were chewed pan with tobacco, and 12.20% used gul.[12] Since ancient times, women in rural areas have largely used Jarda, Khaini, Gul, and Sadapata, SLT as a form of fun and entertainment, but this statistic has been demonstrated to be lower among women workers in smokeless tobacco product industries in other countries. In this study, about 67.32% of respondents think that SLT do not cause harm in the oral cavity while only 32.68% stated that SLT causes harm in the oral cavity.

Among them, one-third (30.3%) of the respondents answered that ulcer occurs in them out due to SLT use, 27.3% thought that it causes stain in the teeth, 12.1% thought that it causes loss of appetite, and 27.3% thought that it causes stain in the teeth and loss of appetite. It was also found that nearly 79.9% of adult American men thought that tobacco snuff increases the risk of cancer whereas 83.8% adult American men considered that chewing tobacco increases cancer risk. Among those who chew tobacco leaves, 71.5% knew the risk associated with it as compared to those who did not chew tobacco.[13],[14],[15] The findings revealed that 32.68 percent of respondents were aware of the harmful impact of SLT products, and the evidence from this study contradicts the previous findings between occupation and regular use of SLT, among the homemakers, 66.2% use SLT regularly, and whereas 84.6% of other group (businesswomen, day laborer, and service holder) use SLT regularly. There was significant association between occupation and regular use of SLT (P < 0.05). Above finding is nearly similar to the study conducted by Parkes J Kendrick. Chewing tobacco was used by 273.9 million individuals (95% UI 258.5–290.9) in 2019, while the age standardized prevalence for people aged 15 and over was 4.72% (446–501).[11] South Asia accounts for 8.329% of chewing tobacco consumers, with India accounting for 18508 million. Palau, Bangladesh, and Nepal, which had 301 million chewing tobacco users in 2019, are other nations with a high prevalence of chewing tobacco use. Tobacco consumption habits were highly prevalent in low monthly family income group and most common among homemakers (40%).[12],[14]

In a study conducted by Mistry SK et al in 2021, 16 percent of women said there had been a significant increase in tobacco use, compared to 31.70 percent among participants in rural areas in this study, while 83 percent of women said tobacco use had decreased significantly, with 68.29 [Table 6] percent during COVID-19 compared to pre-pandemic in this study.[15]
Table 6: Distribution of the respondent's opinion on use of smokeless tobacco during lockdown due to COVID 19 (n=205)

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  Conclusion Top

Even though SLT accounts for more than half of tobacco use among men and women in low-income or developing nations, it receives less attention due to its lower detrimental consequences than smoking and the sociocultural components of tobacco control efforts. Finally, given the negative consequences of its use, the harmful effect of the use of SLT by women is unknown to them, which is sad and often goes unnoticed by women in general. Now is the time for our local political leaders and governments to implement emergency measures and network systems to end the advertising and use of SLT on a national and global level, and to recommend its prohibition, as outlined in the WHO Framework Convention on Tobacco Control.

Scientific rationale and principal findings

  • SLT instruction should be included in general health education programs, and legislation should be enacted to prohibit the sale of SLT to children and adolescents, as well as the negative side effects of using it
  • Systematic community-oriented oral health promotion programs are needed for better control of oral diseases and hazards SLT to be taught in all educational institutions and religious centers to increase health awareness
  • A prevention-oriented oral healthcare policy is, indeed, more advantageous than the curative approach. Health education related to oral health in the educational institutions may provide effective settings for oral health education programs.

Practical Implications

  • The use of SLT products on oral health should be promoted in the media to raise awareness of the harmful consequences of SLT on general and oral health, which are well-known but not well-understood by the general population.
  • Research should be continued into the factors that influences SLT using behavior to determine mere appropriate in health education
  • Though there were very limited studies conducted on SLT, more and more research needs to be performed to help the researcher to give more information as well as discussion needs to be addressed about this problem in the matter.


The sample size may be a limitation of this study.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Asthana S, Labani S, Kailash U, Sinha DN, Mehrotra R. Association of smokeless tobacco use and oral cancer: A systematic global review and meta-analysis. Nicotine Tob Res 2019;21:1162-71.  Back to cited text no. 1
de Geus JL, Wambier LM, Loguercio AD, Reis A. The smokeless tobacco habit and DNA damage: A systematic review and meta-analysis. Med Oral Patol Oral Cir Bucal 2019;24:e145-55.  Back to cited text no. 2
Singh PK, Yadav A, Singh L, Mazumdar S, Sinha DN, Straif K, et al. Areca nut consumption with and without tobacco among the adult population: A nationally representative study from India. BMJ Open 2021;11:e043987.  Back to cited text no. 3
Kamath KP, Mishra S, Anand PS. Smokeless tobacco use as a risk factor for periodontal disease. Front Public Health 2014;2:195.  Back to cited text no. 4
Berg CJ, Ajay VS, Ali MK, Kondal D, Khan HM, Shivashankar R, et al. A cross-sectional study of the prevalence and correlates of tobacco use in Chennai, Delhi, and Karachi: Data from the CARRS study. BMC Public Health 2015;15:483.  Back to cited text no. 5
Gentzke AS, Wang TW, Jamal A, Park-Lee E, Ren C, Cullen KA, et al. Tobacco product use among middle and high school students – United States, 2020. MMWR Morb Mortal Wkly Rep 2020;69:1881-8.  Back to cited text no. 6
Kurlikar P. Smokeless tobacco, associated risk factors and women health: The study of garment workers in urban Mumbai, India. Tob Indu Dis 2018;16:525.  Back to cited text no. 7
Mazurek JM, Syamlal G, King BA, Castellan RM, Division of Respiratory Disease Studies, National Institute for Occupational Safety and Health, CDC. Smokeless tobacco use among working adults – United States, 2005 and 2010. MMWR Morb Mortal Wkly Rep 2014;63:477-82.  Back to cited text no. 8
Hossain MS, Kypri K, Rahman B, Arslan I, Akter S, Milton AH. Prevalence and correlates of smokeless tobacco consumption among married women in rural Bangladesh. PLoS One 2014;9:e84470.  Back to cited text no. 9
Agbor MA, Azodo CC, Tefouet TS. Smokeless tobacco use, tooth loss and oral health issues among adults in Cameroon. Afr Health Sci 2013;13:785-90.  Back to cited text no. 10
GBD 2019 Chewing Tobacco Collaborators. Spatial, temporal, and demographic patterns in prevalence of chewing tobacco use in 204 countries and territories, 1990-2019: A systematic analysis from the Global Burden of Disease Study 2019. Lancet Public Health 2021;6:e482-99.  Back to cited text no. 11
Neufeld KJ, Peters DH, Rani M, Bonu S, Brooner RK. Regular use of alcohol and tobacco in India and its association with age, gender, and poverty. Drug Alcohol Depend 2005;77:283-91.  Back to cited text no. 12
Hossain MS, Kypri K, Rahman B, Milton AH. Smokeless tobacco consumption in the South Asian population of Sydney, Australia: Prevalence, correlates and availability. Drug Alcohol Rev 2014;33:86-92.  Back to cited text no. 13
Sreeramareddy CT, Ramakrishnareddy N, Harsha Kumar H, Sathian B, Arokiasamy JT. Prevalence, distribution and correlates of tobacco smoking and chewing in Nepal: A secondary data analysis of Nepal Demographic and Health Survey-2006. Subst Abuse Treat Prev Policy 2011;6:33.  Back to cited text no. 14
Mistry SK, Ali AM, Rahman MA, Yadav UN, Gupta B, Rahman MA, et al. Changes in Tobacco use patterns during COVID-19 and their correlates among older adults in Bangladesh. Int J Environ Res Public Health 2021;18:1779.  Back to cited text no. 15


  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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