Prevalence of Oral Potentially Malignant Lesions, Tobacco use, and Effect of Cessation Strategies among Solid Waste Management workers in Northern India: a pre-post intervention study.

BACKGROUND: India bears the highest global burden of oral cancer, despite having an operational tobacco cessation framework. Occupational groups like solid waste management personnel face significant health challenges due to prevalent tobacco use, leading to oral potentially malignant lesions and oral cancer. Enhanced tobacco control strategies are essential for these groups. METHODS: A pre-post interventional, community-based study enrolled 1200 municipal workers in Varanasi, India, from July 2022 to August 2023. 858 tobacco users underwent screening and were randomly assigned to one of three interventions: Very Brief Advice, Individual Behavioral Counseling, or Group Behavioral Therapy. Follow-up was conducted one year after the baseline interventions Effectiveness was measured by nicotine dependence reduction using the Fagerstrom Test for Nicotine Dependence (FTND) scores and cessation rates defined as at least 6-month abstinence. Appropriate statistical tests assessed the burden of tobacco use, oral potentially malignant lesions, and pre-post differences in FTND scores within and between groups. A p-value of < 0.05 was considered statistically significant. RESULTS: Municipal workers exhibited a high prevalence (71.5%) of smokeless tobacco (SLT) use. One-third (32.9%) of the participants screened positive for oral potentially malignant lesions and oral cancer. Leukoplakia was the most common lesion. Screened positivity correlated with significant nicotine dependence. Among 494 follow-up participants, 47.1% reported a significant reduction in nicotine dependence across all intervention groups. Quade's ANCOVA indicated significant differences in post-test FTND scores, with individual behavioral counselling showing the greatest reduction. However, no cessation was achieved in any group despite the significant decline in dependence. CONCLUSION: Solid waste management personnel in Varanasi show heightened SLT use and associated oral potentially malignant lesions. The persistent tobacco use in these high-risk occupational populations undermines government tobacco control efforts and highlights the need for robust policy and implementation strategies. The study demonstrated a significant reduction in nicotine dependence following interventions, though tobacco cessation was not achieved. More frequent interventions and addressing quitting barriers-such as cultural norms, lack of awareness, easy accessibility, and adverse working conditions-are crucial. Developing a tailored workplace model to tackle tobacco use in occupational settings may facilitate cessation. CLINICAL TRIAL REGISTRATION NUMBER: Trial registration Clinical Trials Registry India CTRI/2020/07/026479. Date of registration 10/07/2020.

Efficacy of daily versus intermittent oral iron supplementation for prevention of anaemia among pregnant women: a systematic review and meta-analysis.

Background: The World Health Organization recommends daily oral supplementation of iron for prevention of maternal anaemia. However, the adverse effects due to daily supplementation leads to poor compliance among pregnant women. Also, the mucosal block theory suggests that intermittent oral iron may be more efficient than daily iron with respect to optimum absorption. Our meta-analysis reviewed the existing clinical studies for the efficacy of daily versus intermittent oral iron supplementation. Methods: In this systematic review and meta-analysis [PROSPERO ID:CRD42024498180], we searched PubMed, Google Scholar, Scopus, Science Direct and Cochrane database for studies published from 1st January 1970 to 31st December, 2023. Studies comparing daily and intermittent iron supplementation in pregnant women were included. The median intermittent iron dose was 120 mg/day and daily iron dose was 60 mg/day. The primary outcome was endpoint haemoglobin levels after iron supplementation. The data was analysed using the 'meta' and 'metafor' packages in RStudio using random effects model. The heterogeneity, publication bias, risk of bias and certainty of evidence were assessed using I2 statistics, funnel plots, Cochrane Risk of Bias 2 (ROB2) tool, and the Grades of Recommendation, Assessment, Development and Evaluation (GRADE) approach respectively. Findings: Of 4615 search results, 26 studies (n = 4365 participants) were included in this meta-analysis. There was no significant difference (p = 0.18) between the endpoint mean haemoglobin levels of the daily versus intermittent oral iron groups (standardized mean difference (SMD): 0.51, 95% CI: -0.23 to 1.24, I2 = 97%, low certainty evidence) irrespective of baseline anaemic status. However, the endpoint ferritin levels were significantly higher in the daily supplementation group (SMD: 0.85, 95% CI: 0.15-1.54, p = 0.02, I2 = 97%, low certainty evidence). The adjusted odds ratio for nausea, (adjusted odds ratio (OR) 3.56, 95% CI: 2.23-5.69, p < 0.001, I2 = 9%, moderate certainty evidence), diarrhoea (adjusted OR 5.40, 95% CI: 1.90-15.33, p = 0.002, I2 = 0%, low certainty evidence) and constipation (adjusted OR 1.95, 95% CI: 1.21-3.14, p = 0.006, I2 = 0%, moderate certainty evidence) was significantly higher in daily oral iron supplementation group. Interpretation: Intermittent oral iron supplementation with a median dose of 120 mg/day demonstrates comparable efficacy to daily oral iron supplementation median dose of 60 mg/day in increasing haemoglobin levels among pregnant women with a significant reduction in adverse events. Funding: There was no funding for this study.

Exploring factors influencing the perspective regarding HIV transmission and prevention among college students in India.

Objective and Design: Although many studies have been conducted to assess the knowledge and practices among healthcare workers, high-risk groups or medical students, very few studies have been conducted among college students from non-medical backgrounds. Our study aimed to assess the knowledge, attitudes and perception about human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) among the college students of the Mumbai region and to determine their association with the socio-demographic variables. Setting and Methods: A cross-sectional online and offline questionnaire survey was conducted among 401 college students from the month of August 2022 to October 2022. Mean score and percentage were used to analyse the data. Results: About 82.04% of participants exhibited good knowledge about HIV transmission and prevention, while 46.38% had a positive attitude towards HIV. Age, gender, religion and education had not influenced either knowledge or attitude significantly. Overall, knowledge score had a weak positive correlation with attitude of the participants. Conclusion: Our study findings indicate that a holistic approach covering knowledge, psychological and societal health aspects is necessary among youth in India for positive changes in people's behaviour and achieving HIV prevention and management goals which will benefit public health at large.

Efficacy of combined HBsAg, anti-HBc and anti-HBs screening in minimizing transfusion transmission risk of hepatitis B infection in low resource setting.

Background: Hepatitis B Virus (HBV), and occult Hepatitis B in particular, is a major concern in the transfusion scenario, especially in endemic countries. This study attempted to estimate the prevalence of occult Hepatitis B infection (OBI) among voluntary blood donors in Maharashtra and to evaluate the role of combined screening strategy with implications in minimizing the current transfusion risks of seropositive OBI. Methods: Donor samples were collected from 80 eligible blood banks from various districts of Maharashtra between 2014 and 2017. ELISA based screening of HBsAg, anti-HBc (total and IgM), anti-HBs titres. Real-time quantitative PCR for Hepatitis B Virus DNA (HBV DNA) were performed for all HBsAg and or anti-HBc positive samples. Results: Out of 2398 samples tested, 20 (0.83%) samples were positive for HBsAg, whereas 547 (22.81%) were positive for anti-HBc. Out of 547 samples, 16 (2.92%) were positive for HBV DNA with median level at 247.89 IU/mL (IQR: 126.05-666.67 IU/mL). Anti-HBs levels were positive in 35.83% of OBI cases. ROC curve analysis showed that combined HBsAg, anti-HBc and anti-HBs (>50 mIU/mL) screening can more efficiently detect HBV infection in blood donors than HBsAg alone. Conclusions: A combined HBsAg, anti-HBc and anti-HBs screening for donor samples could be an alternative achievable strategy to minimize the HBV transmission as well as financial burden. In resource limited setup, the proposed combined strategy could be helpful in minimizing the risk of OBI transmission.

Role of hydroxyurea therapy in the prevention of organ damage in sickle cell disease: a systematic review and meta-analysis.

BACKGROUND: Hydroxyurea is an affordable drug that reduces vaso-occlusive crises and transfusion requirements in sickle cell disease. However, its effectiveness in preventing chronic organ damage is still unclear. This systematic review and meta-analysis aimed to evaluate the role of hydroxyurea in preventing organ morbidity. METHOD: We included original articles published in English from 1st January 1990 to 31st January 2023, reporting hydroxyurea therapy and organ damage from PubMed, Google Scholar, Scopus, and CrossRef databases. A total of 45 studies with 4681 sickle cell disease patients were evaluated for organ damage. RESULTS: Our analysis showed that hydroxyurea intervention significantly lowered transcranial Doppler and tricuspid regurgitant velocity, with a standardized mean difference of - 1.03 (- 1.49; - 0.58); I 2 = 96% and - 1.37 (CI - 2.31, - 0.42); I 2 = 94%, respectively. Moreover, the pooled estimate for albuminuria showed a beneficial effect post-hydroxyurea therapy by reducing the risk of albuminuria by 58% (risk ratio of 0.42 (0.28; 0.63); I 2 = 28%). CONCLUSION: Our study found that a hydroxyurea dose above 20 mg/kg/day with a mean rise in HbF by 18.46% post-hydroxyurea therapy had a beneficial role in reducing transcranial doppler velocity, tricuspid regurgitant velocity, albuminuria, and splenic abnormality. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42023401187.

Exploring risk factors and transmission dynamics of Hepatitis B infection among Indian families: Implications and perspective.

INTRODUCTION: Hepatitis B virus (HBV) is global health problem. Family members of HBV infected people are considered as high-risk groups due to frequent household transmission of HBV among contacts of HBsAg carriers. The present study aimed to investigate the intrafamilial transmission of HBV among family members of HBV-infected persons and to identify the risk factors for viral transmission in these setting. METHODS: 361 index cases and their 1083 family contacts were tested for markers of Hepatitis B, viz. HBsAg and HBcAb using commercial ELISA. The demographic details and risk factors for acquiring HBV infection among the family members were recorded using a structured questionnaire. RESULTS: The median (IQR) age of index cases and family members was 37 (27 - 48) and 26 (14 - 38) years, respectively. Among the screened family members, 9.23% (n = 100) members were positive for HBsAg and 32.75% (n = 355) were positive for HBcAb. At least one member of the family was affected in 229/361 (63.43%) index cases. Significantly lower percent of household contacts (9.23%, n = 100)were vaccinated against HBV.HBV transmission risk was significantly higher in families with more than four members(p < 0.0001). Multinomial logistics regression analysis for familial risk factors for transmission of HBV such asclose contact with carrier (aOR overt: 1.172, aOR occult: 1.173), sharing of bed/bedding (aOR overt: 1.258, aOR occult:1.264), personal hygiene items (aOR overt:1.260, aOR occult: 1.451), and eating in common utensils (aOR overt: 2.182, aOR occult: 1.307)were significantly associated with the transmission of HBV (p < 0.05). DISCUSSION: Close contact with carrier, sharing of bed/bedding or personal hygiene items and eating in common utensils were significantly associated with the transmission of HBV. Increasing awareness about Hepatitis B infection and vaccination of family members in close contact with carrier is essential to prevent Hepatitis B transmission.

Impact of COVID-19 infection among indian sickle cell disease patients.

Background: Sickle cell disease (SCD) is one of the most common hemoglobinopathy disorders and is widely prevalent in India, especially in the tribal population. SCD patients are prone to develop recurrent respiratory infections and related complications owing to the microvascular occlusion and impaired immunological response. Objectives: We aimed to determine the prevalence and impact of COVID-19 in SCD patients from India. Methodology: We conducted a cross-sectional study in Chandrapur district of Maharashtra, India, between August and October 2021. After taking informed consent, details of 300 SCD patients' demographic data, history of COVID-19 testing, infection, symptoms related to COVID-19 in the past 1 year, hospitalization, complications, mortality, COVID-19 vaccination, and side effects were recorded. Results: We found that 93 (31%) of SCD patients had influenza-like symptoms during the COVID-19 pandemic with symptoms of fever (81.72%), cough (35.48%), sore throat (18.27%), headache (15.05%), and breathlessness (7.52%). A total of 13 (4.33%) SCD among 300 SCD were tested as COVID positive. Majority of them were mild cases and the 1st dose of COVID-19 vaccine was received by 47 (29.37%) of SCD patients and 10 (6.02%) of the patient had received second dose of vaccine. Conclusion: Low incidence of COVID-19 and milder disease spectrum in our study cohort suggests that there is no increased risk of COVID-19 mortality and morbidity in SCD patients compared to general population. However, the reason for low COVID vaccination in our study could be due to the fear of complications of COVID vaccine.

Cancer pattern in Varanasi district from Uttar Pradesh state of India, a foundation for cancer control based on the first report of the population-based cancer registry.

Background: The cancer registry provides reliable data from the population. In this article, we provide cancer burden and its patterns from the Varanasi district. Methods: The method adopted by the Varanasi cancer registry is community interaction along with regular visits to more than 60 sources to collect data on cancer patients. The cancer registry was established by the Tata Memorial Centre, Mumbai, in 2017 covering 4 million population (57% rural and 43% urban population). Results: The registry has recorded 1,907 incidence cases (1,058 male and 849 female). The age-adjusted incidence rate per 100,000 population in male and female of Varanasi district is 59.2 and 52.1, respectively. One in 15 male and one in 17 female are at risk of developing the disease. Mouth and tongue cancers are the predominant cancers in male, whereas breast, cervix uteri, and gallbladder are the leading cancer sites among the female. In female, cervix uteri cancer is significantly higher (double) in rural areas when compared with urban areas (rate ratio [RR] 0.5, 95% confidence interval [CI; 0.36, 0.72]), whereas in male, mouth cancer is higher in urban areas when compared with rural areas (RR 1.4, 95% CI [1.11, 1.72]). More than 50% of cancer cases in male are due to tobacco consumption. There may be underreporting of the cases. Conclusion: The results of the registry warrant policies and activities related to early detection services for the mouth, cervix uteri, and breast cancers. The Varanasi cancer registry is the foundation for cancer control and will play an important role in the evaluation of the interventions.

Chronic Hepatitis B and Related Liver Diseases Are Associated with Reduced 25-Hydroxy-Vitamin D Levels: A Systematic Review and Meta-Analysis.

Hepatitis B infection is a major public health problem globally leading to chronic liver disease and death, which are influenced by various environmental and host factors including serum 25-hydroxy-vitamin D levels. There is no comprehensive systematic review reporting the association of serum 25-hydroxy-vitamin D levels and different stages of chronic hepatitis B. This study aimed to analyze the association of 25-hydroxy-vitamin D levels in chronic hepatitis B with various determinants and outcomes. A bibliographic search in PubMed, Google Scholar, and Scopus was conducted using the search terms "Vitamin D", "cholecalciferol", "calcitriol", "Hepatitis B", and "HBV", which were published until September 2022. Meta-analysis using the "metafor" package in R was conducted with a random effect model. This analysis included 33 studies with 6360 chronic hepatitis B patients. The pooled estimates of serum 25-hydroxy-vitamin D level among CHB cases was 21.05 ng/mL and was significantly lower compared to healthy controls. (p < 0.005). Reduced serum 25-hydroxy-vitamin D level was significantly associated with the severity of liver fibrosis as well as HBe positivity. This analysis suggests that serum 25-hydroxy-vitamin D levels are associated with disease activity and pathobiology, although the exact nature of the cause−effect relationship cannot be discerned from this study.

A Cross Sectional Assessment of the Profile of Risk Factors of Non-Communicable Diseases Among Health Care Staff of a Tertiary Cancer Hospital.

Background: Non-communicable disease (NCD) is the leading cause of death, accounting for 70% of total death globally, and posing a major public health challenge. In India, nearly 5.8 million people (WHO report, 2015) die from NCDs every year. The basic element of NCD prevention is the identification of the associated risk factors and risk modification. The objective of the current study was conducted to assess the prevalence of risk factors for NCDs among healthcare staff of the two units of a Tertiary Cancer Hospital in Varanasi, India, using WHO STEPS approach. Methods: This cross sectional study was conducted among 528 participants who were willing to participate in the study, from among 967 healthcare staffs of the two units of the Tertiary Cancer Hospital. The participants were interviewed and the anthropometric and biochemical parameters were measured. Results: The prevalence of risk factors, associated with NCD, tobacco use, alcohol use, extra salt in diet, less than 5 servings of fruits/vegetables, physical inactivity and self-perceived high stress score was found in 34 (6.43%), 90 (17.04%), 461 (87.3%), 412 (78.03%), 409 (77.4%) and 159 (30.11%) respondents, respectively. Multiple logistic regression revealed that Diabetes was significantly associated with male sex, high BMI and physical inactivity. Hypertension was found significantly associated with male sex, increasing age, tobacco and or alcohol consumption, high BMI and high stress. Dyslipidemia was also found significantly associated with high BMI, male sex, physical inactivity and high stress levels. Conclusion: A high prevalence of risk factors for NCDs was found among the healthcare staff and it is the need of the hour to take preventive measures to reduce the prevailing burden of NCD.

A systematic review on hydroxyurea therapy for sickle cell disease in India.

Background & objectives: Sickle cell disease (SCD) constitutes frequently inherited haemoglobin disorders and poses a significant health burden in India. Hydroxyurea (HU), the most commonly used drug, has shown promising results in the clinical management of SCD. The present systematic review was undertaken to assess the efficacy and toxicity of HU in Indian sickle cell patients. Methods: A systematic review of studies on HU therapy was conducted to identify the application of HU and its outcome(s) across India. PubMed, Scopus and Cochrane Library was used as data sources for various studies on the efficacy and toxicity of HU therapy for treatment for SCD in India published between January 2001 and October 2021. Two authors independently extracted the data on study design, patient characteristics and therapeutic outcomes of HU in order to determine the study quality of the present review. Results: Overall, 14 studies were included for a systematic analysis. Of these 11 were prospective, two cross-sectional and one double-blind randomized controlled trial. Low-dose HU (10 mg/kg/day) was found to reduce the rates of vaso-occlusive crisis and hospitalization as well as decreased the requirement of blood transfusion in SCD patients. The foetal haemoglobin (HbF) level was recorded in 13 (80%) studies all of whom reported an elevation in the HbF levels, with a mean increase in per cent HbF from 15.8 to 21.4 per cent across studies. The common adverse events were reversible, mild-to-moderate cytopenia and anaemia. Interpretation & conclusions: The findings of the present review suggest that there is still insufficient information presently to determine the long-term or major adverse effects on organ damage, fertility as well as pregnancy on the use of HU therapy for SCD. Long-term multi-centric studies are thus required to address these problems.

Comparative study of clinical features and vaccination status in Omicron and non-Omicron infected patients during the third wave in Mumbai, India.

Objectives: The Omicron variant-mediated COVID-19 wave is responsible for a global tsunami of cases. There is scarce data about the clinical and epidemiological characteristic analyses of the third wave. We present the data of COVID-19 patients from Mumbai region during the early third wave by taking S-gene target failure (SGTF) as a proxy for probable Omicron cases. Methods: We collected retrospective data of RT-PCR-confirmed (COVID-19) patients, and measured the proportion of possible Omicron cases by SGTF. We segregated and analyzed the clinical and lab data of patients with outcomes such as differing symptoms, vaccination coverage, previous infection, and travel history. We also performed a trend analysis of Mumbai's COVID-19 data before and during the third wave. Results: All patients had mild clinical symptoms while few were asymptomatic. Myalgia was more significantly present in SGTF/Omicron cases compared to non-SGTF/Delta patients. Out of the total 101 COVID-positive individuals, 94 individuals (93%) had taken two doses of COVID vaccine. Among these 94 individuals, 9 (8.9%) had been previously infected with COVID 19 in the first or second waves. 77.7% of the previously infected were now infected with Omicron variant and only 22.3% by a non-Omicron variant. Conclusion: Rapid rise and fall during the third wave in Mumbai was due to Omicron cases gradually replacing Delta. The overall milder clinical spectrum in both Omicron and Delta cases imply that vaccines might not be effective against re-infection but can attenuate disease severity and mortality, as evident by high coverage of vaccination in the country.

Epidemiological study of adverse events following immunization in under 5 year children.

BACKGROUND: The present study was conducted to study the socioeconomic and the demographic profile of children reporting with adverse events following immunization (AEFI) along with the determinants associated with AEFIs, based on investigation of each case and to assess the proportion of programmatic errors linked with AEFI cases. MATERIALS AND METHODS: Record-based cross-sectional study conducted among sample of 118 cases of AEFI were reported. The case reports of all AEFI cases were procured and analyzed to identify factors associated with reported AEFI. The questionnaires related with preliminary investigation reports (PIRs) including forensic evidence of death cases were analyzed. Percentage analysis of data was done by proportions, measures of central tendencies, and Chi-square test. RESULTS: Most of the cases reported were between 0 and 3 months of age constituting 39%. AEFI was seen more in male child than female. more than half of cases of AEFI were recorded following immunization with OPV/DPT/HBV together (66.94%). Most common AEFI reported were convulsion (68.64 %) and fever (58.47%) followed by local swelling at site of injection (11.86%). More than half of the cases of AEFI occurred within 12 hours of immunization (61.88%). Birth weight of most cases of AEFI were in the range between 2 and 2.4 kg (44.06%), followed by range between 2.5 and 2.9 kg (32.20%), the mean of birth weight was 2.51 kg. CONCLUSION: Convulsion was the most commonly reported AEFI, majority of AEFI occur within 12 h of immunization. Most of the AEFI were recorded following immunization with OPV/DPT/HBV together.

Implementation of Early Detection Services for Cancer in India During COVID-19 Pandemic.

Early detection of cancer greatly increases the chances of better survival. The emergence of COVID-19 pandemic has disrupted several essential health services globally and early detection of cancer services is one of them. The routine cancer screenings have plummeted in many developed countries since the crisis. India has highest estimated lip and oral cavity cancer cases worldwide (119,992, 33.8%) and the secondhighest number of breast (162,468, 17.8%) and cervix uteri (96,922,30.7%) cancers in Asian sub-continent. Not only India has high burden of cancer, but the majority (75-80%) of patients have advanced disease at the time of diagnosis. Hence is it imperative that early detection services should be kept functional at out-patient settings so that at least the patients coming to hospitals with early signs and symptoms can be diagnosed as early as possible. Strategies need to be adopted to continue early detection services and ensure safety of patients and health care workers from COVID-19 transmission.

Knowledge, attitude, and practice about cervical cancer and its screening among community healthcare workers of Varanasi district, Uttar Pradesh, India.

CONTEXT: Cervical cancer is most common type of cancer in women of rural India. More than 60-70% of cancers are diagnosed in later stages with poor survival rate. Screening helps in early detection of cervical cancer and better survival. Awareness and attitude of women towards cervical cancer screening may determine health-seeking behavior. As per operational framework of cancer screening in India, community health workers will be key mobilizers for encouraging women to undergo cervical cancer screening. AIM: This study aims to assess the knowledge, attitude and practice (KAP) of cervical cancer and its screening amongst community health workers of Varanasi district, Uttar Pradesh. SETTINGS AND DESIGN: Descriptive, cross-sectional study was done to assess the socio demographic profile and KAP for cervical cancer and its screening of community health workers. Scoring for awareness and attitude for cervical cancer screening was done. STATISTICAL ANALYSIS USED: Descriptive statistics such as mean±SD, frequency and proportion were used for socio-demographic data and KAP of study population. Determinants of knowledge and practice for screening was determined using Chi-square test. P value < 0.05 was considered statistically significant. RESULTS: We observed that despite of good knowledge and perception less than 10 percent of workers have undergone screening. Significant association was seen between level of knowledge and practice of screening. CONCLUSION: It is of utmost importance that narrowing of existing gap between the perception and practice of cervical cancer screening should be initiated through introducing more educational programs for workers and encouraging them to participate in screening campaigns.

Determinants of Tobacco Use and Prevalence of Oral Precancerous Lesions in Cab Drivers in Bengaluru City, India.

BACKGROUND: Tobacco is a most important risk factor for various types of cancer as well as some noncommunicable disease. Around 34.6% of Indian population consume tobacco. The tobacco consumption is higher in some vulnerable population such as drivers, daily wage laborers, and policemen. Tobacco consumption is known to cause oral cancers, and screening for oral cancer in these individuals is known to reduce mortality from cancer. The study was designed to assess the determinants of tobacco use and the prevalence of oral precancerous lesions in cab drivers. METHODS: This is a cross-sectional study among cab drivers at prepaid taxi counters in Bengaluru city. A total of 450 cab drivers were enrolled in the study, of which 225 cab drivers were interviewed during morning hours and remaining half at night time using a semi-structured questionnaire. All were screened for oral cancer/precancerous lesions. RESULTS: Nearly 70.88% of cab drivers were consuming tobacco in any form. Long working hours, working at night, and family members consuming tobacco were significant risk factors for tobacco use among cab drivers. Forty-eight drivers were detected to have oral precancerous lesions. CONCLUSIONS: It was very evident that long hours of driving and infrequent shifts played a greater role in acquiring the habit. Behavioral counseling and new laws need to be formed to limit the working hours in drivers to have an effective tobacco control.