Why do Adolescents Initiate and Continue Using Tobacco and Areca Nut?: A Qualitative Study Tracing Pathways of Use Among School-Going Adolescents in Mumbai, India.

BACKGROUND: Tobacco and areca-nut use among adolescents has been reported from different parts of India. Multiple factors influence initiation of tobacco use among adolescents. Initiation of one product gradually extends to multiple products. Studies on initiation lack documentation of the pathways and experiences post-initiation, which is required to holistically understand behavior patterns of adolescents for planning timely intervention. This study was conducted to trace pathways and identify factors influencing the initiation and continuation of tobacco and areca-nut among adolescents. METHODS: In this two-staged study, we conducted 14 focus group discussions (FGDs) with 166 adolescents studying in grades 7-9 (11-18 years) from six municipal schools in Mumbai, India. They had self-reported areca-nut or smoked or smokeless tobacco (SLT) use. Pathways of initiation were traced through in-depth interviews for 60 adolescents. RESULTS: Four multi-linear pathways of use were identified: (1) areca-nut only, (2) areca-nut to tobacco, (3) initiation with SLT, and (4) initiation with smoking. Raw or sweetened areca-nut, betel leaf, gutka, masheri, mawa, hookah, cigarette, bidi, and e-cigarettes were products reported to be used. Curiosity, easy access to tobacco products and normalization of tobacco use influenced initiation. Areca-nut acted as a precursor to tobacco use. CONCLUSION: Tracing pathways in tobacco use helped to understand reasons for initiation, influences in continuation of use, and experiences of significance to the adolescents. Experiences of adolescents play a critical role in shaping the pathways of tobacco use. Understanding the pathways and influencers will further help to build effective health promotion communication, policies for sale to minors, and school-based cessation interventions. IMPLICATIONS: Findings of the study provide an insight into unknown areas of information regarding products used by adolescents, their patterns of consumption, perceptions, and their pathways of initiation and continuation of primary and secondary products. This will help in developing specific public health awareness messages, policies regarding packaging and sale of areca-nut to children and interventions targeted for the adolescents and their specific products of use not just in India but for the South-East Asia region as areca-nut and tobacco use among adolescents is common in the region. The exercise of tracing the pathways provides basis for cessation counseling among adolescents.

Tobacco Use and Subsequent Cessation Among Hospitalized Patients in Mumbai, India: A Longitudinal Study.

INTRODUCTION: Hospitalization is an important setting to address tobacco use. Little is known about post-discharge cessation and treatment use in low- and middle-income countries. Our objective was to assess tobacco use after hospital discharge among patients in Mumbai, India. METHODS: Longitudinal observational study of inpatients (≥15 years) admitted at one hospital from November 2015 to October 2016. Patients reporting current tobacco use were surveyed by telephone after discharge. RESULTS: Of 2894 inpatients approached, 2776 participated and 15.7% (N = 437) reported current tobacco use, including 5.3% (N = 147) smokers, 9.1% (N = 252) smokeless tobacco (SLT) users, and 1.4% (N = 38) dual users. Excluding dual users, SLT users, compared to smokers, were less likely to report a plan to quit after discharge (42.6% vs. 54.2%, p = .04), a past-year quit attempt (38.1% vs. 52.7%, p = .004), to agree that tobacco has harmed them (57.9% vs. 70.3%, p = .02) or caused their hospitalization (43.4% vs. 61.4%, p < .001). After discharge, 77.6% of smokers and 78.6% of SLT users reported trying to quit (p = .81). Six-month continuous abstinence after discharge was reported by 27.2% of smokers and 24.6% of SLT users (p = .56). Nearly all relapses to tobacco use after discharge occurred within 30 days and did not differ by tobacco type (log-rank p = .08). Use of evidence-based cessation treatment was reported by 6.5% (N = 26). CONCLUSIONS: Three-quarters of tobacco users in a Mumbai hospital attempted to quit after discharge. One-quarter reported continuous tobacco abstinence for 6 months despite little use of cessation treatment. Increasing post-discharge cessation support could further increase cessation rates and improve patient outcomes. IMPLICATIONS: No prior study has measured the patterns of tobacco use and cessation among hospitalized tobacco users in India. Three-quarters of tobacco users admitted to a hospital in Mumbai attempted to quit after discharge, and one-quarter remained tobacco-free for 6 months, indicating that hospitalization may be an opportune time to offer a cessation intervention. Although smokers and SLT users differed in socioeconomic status, perceived risks and interest in quitting, they did not differ in their ability to stay abstinent after hospital discharge.