We studied tobacco use and nicotine dependency in a representative sample of 18,018 individuals in the 14 plus age group in Andaman and Nicobar Islands in India. This is the first such study conducted in the Union Territory of Andaman and Nicobar Islands. The proportion of individuals in our sample population representing the various social groups are similar to the total population proportion of these groups in the Andaman and Nicobar Islands [6
]. The sample estimates are therefore very close to the true population estimates. Our study highlights relatively high prevalence of tobacco use in this population (almost 50%). Furthermore, tobacco chewing was the main form of tobacco use.
Almost 58% of the males and 11% of the females were current tobacco users in the National Family Health Survey-3 [NFHS-3] (2005–2006) conducted among individuals aged 15–54
years in 29/35 states and Union Territories in India [3
]. In NFHS-3, around 36% of the males and 8% of the females reported use of smokeless tobacco in the form of chewing [3
]. While 47.9% of the males and 20.3% of the females were current tobacco users in the GATS, the overall prevalence was 34.6%. Furthermore, more than a quarter (26%) of the GATS respondents from India reported use of smokeless tobacco [4
]. However, NFHS-3 and GATS did not cover the Union Territory of Andaman and Nicobar Islands [3
]. The use of tobacco among women in our study is almost four times (33%) higher than that of NFHS-3 survey. Furthermore, in Andaman and Nicobar Islands chewing is the main form of tobacco use and there are different patterns of tobacco chewing prevalent i.e., use of Zarda Pan, Kagaz pan, Sookha, Khaini
, and Gutkha
Although the overall nicotine dependence rate was only 6.4% in the study population (13.1% among current tobacco users), it was nearly 30% among users of tobacco in mixed form (both chewing and smoking). To the best of our knowledge this is the largest ever community based survey conducted in India to assess the prevalence of nicotine dependence using FTND tool. The FTND is a screening instrument for physical nicotine dependence and is extensively used in various countries. Although, the reliability of this screening tool is questioned in several small studies, it was found to be reliable in different settings and populations [22
]. However, further studies of the FTND are needed in the Indian population to assess the validity and reliability of this instrument.
The mean age of initiation of tobacco use was lower in males and in the younger age groups in the study population. The trend observed in males and females with age indicates that the age of onset of tobacco use is coming down in individuals in the newer generation. Furthermore, three fourth of the tobacco users initiated use of tobacco before reaching 21
years of age. This trend is disturbing as it is important to increase the tobacco free years of life in order to reduce the harmful effect of tobacco at the population level.
There were distinct social patterns observed for tobacco use and nicotine dependency in our study. While the prevalence of tobacco use was higher in the Nicobarese tribe, the risk of nicotine dependence was highest among Ranchi groups. Car Nicobar Island in the southern district of Nicobar is totally inhabited by Nicobarese aboriginal tribe. Although, they are aboriginal people, they are no more considered as primitive. More importantly, the overall literacy of Car Nicobar Island is around 75%. Though the tsunami of 2004 devastated the life of tribal living in this island, still they maintain their traditional cultural and social rituals in their daily life [23
]. On the other hand, there are over sixty five thousand ‘Ranchi tribes’ (Ranchis) people live in Andaman and Nicobar Islands. During the British rule, since 1918, people from the Chhota Nagpur tribal belt of mainland India were brought to Andaman and they were forced to work as forest labourers. They are known as ‘Ranchis’. Even after India’s independence Ranchis were brought to Andaman and Nicobar Islands as labourers to clear forest areas for settlements. While these communities are recognised as Scheduled Tribes (ST) in their region of origin, they are seen simply as a homogenous group of migrants in Andaman and Nicobar Islands. The Ranchis own no land and rely on irregular labour jobs for survival. While, the STs have fixed quota of benefits for education, employment and other social security measures that are guaranteed under the Indian constitution, the Ranchis are deprived of all these facilities because of their social position. With labour work increasingly insecure, health and education of the community also suffers [24
]. While Nicobarese reported to have high prevalence of tobacco use, the risk of nicotine dependence was highest in Ranchis in our study. The phenomenon of ‘anomie’ (the breakdown of social bonds between individuals and loosening of their community ties with fragmentation of social identity and rejection of self regulated values) which is evident in the uprooted "Ranchi tribes" and the subsequent substance abuse may partially explain this paradox [25
Alcohol use was the most significant determinant of tobacco use and nicotine dependence in the study population. Alcohol consumption and tobacco use are closely linked behaviours and importantly people who drink larger amounts of alcohol tend to smoke more cigarettes. Furthermore, smokers who are dependent on nicotine have a 2.7 times greater risk of becoming alcohol dependent than nonsmokers [27
]. Therefore, the issue of tobacco control cannot be seen in isolation from control of alcohol abuse.
There was a significant inverse and graded relationship between educational status and tobacco use or nicotine dependence rate. Similar trends in tobacco use are also observed in various population based studies from India [28
]. Post traumatic stress disorders neither increase the tobacco use nor have an impact on nicotine dependence rate. This data is of particularly important in the context of the devastating Tsunami event happened three years before the survey in the Andaman and Nicobar Islands. PTSD was assessed using trauma screening questionnaire and in general the overall efficiency of this instrument is found to be equivalent to that obtained from DSM-IV PTSD module [13
The strengths of our study include population based survey methodology covering more than 18,000 individuals, including both males and females in the survey and an overall response rate of 97% (18,018/18,554). The field interviewers visited the houses and Tuhets on multiple occasions to achieve this high response rate. This is probably the highest response rate in a survey of this magnitude conducted in India. While our findings are generlizable to the population of Andaman and Nicobar Islands, the use of standard survey instruments increases the validity of our findings.
The cross-sectional nature of our study and self reported rates of tobacco use are the major limitations of our study. Thus the results demonstrate associations but do not provide evidence for causality. The possibility of underreporting of some of these additive behaviours may be present due to its social unacceptability in certain segments of the society.
Population data of prevalence estimates of tobacco use, pattern of tobacco use, and determinants of tobacco use and nicotine dependence are important baseline information that influences policy decisions on development and implementation of tobacco control strategies. The high prevalence of tobacco use especially the chewing form of tobacco in the Union Territory of Andaman and Nicobar Islands and the distinct social pattern observed for tobacco use and nicotine dependency warrants implementation of culturally specific tobacco control activities in this population. The relatively higher proportion of females using tobacco products in this region and high prevalence in individuals in the low educational status group also requires special attention while developing tobacco control strategies. Furthermore, special tobacco cessation clinics may be required for individuals who report nicotine dependence. Although, the nicotine dependence prevalence rate is relatively low (6.4%), the absolute number of individuals with nicotine dependency in the population is very high. For example, with the current prevalence estimate more than 20,000 individuals are nicotine dependent in the Union Territory of Andaman and Nicobar Islands. Treatment outcomes for patients addicted to both alcohol and nicotine are generally worse than for people addicted to only one drug, and many treatment providers do not promote smoking cessation during alcoholism treatment. Hence, tobacco control activities should go hand-in-hand with control of alcohol use in this population as the combined use of tobacco and alcohol is very high in this population.