<figure><img src="image_1.png" /></figure>

<figure><img src="image_2.png" /></figure>

ORIGINAL ARTICLE

# Prevalence of Tobacco Use among Adults in Rural Areas of Kanyakumari District, Tamil Nadu - A community-based study

Sivaanusuya SUDHAKARAN¹, Jayanandhini ANANDHAJOTHI², Hemavathe SIVAJI³

## ABSTRACT

**Background:** Tobacco refers to any product prepared from the tobacco plant and is an addictive substance containing the stimulant alkaloid nicotine as well as harmala alkaloids, which can lead to tolerance and dependence. All smoking and smokeless forms of tobacco contain nicotine, which causes addiction and health problems. **Objectives:** This study aimed to assess the prevalence and factors associated with tobacco use among adults aged 18 years and above in the rural area of Kanyakumari district, Tamil Nadu. **Methodology:** A community-based cross-sectional study was conducted among adults aged ≥18 years in Thiruvattar block, Kanyakumari district, from February 2019 to July 2020, using a semi-structured questionnaire. Data were entered into MS Excel 2010 and analyzed using SPSS Trial Version 20.0. **Results:** The prevalence of tobacco use was 22.4% for current users, 2.8% for past users, and the prevalence of never users was 74.8%. The mean age of initiation was 18.03 ± 2.92 years. Awareness regarding tobacco and its adverse health effects was 70.8%. Significant associations were found between tobacco use and gender, age group, education, occupation and socioeconomic status (SES), with p-values < 0.05. **Conclusion:** Despite high awareness of health hazards, tobacco use was more prevalent among young adults, married males, individuals from nuclear families and skilled/semi-skilled workers. Focus group discussions, anti-tobacco measures and early-life awareness programs should be prioritized for primary prevention among rural populations.

**Keywords:** smoking prevalence, rural health, epidemiology, smokeless tobacco, public health.

1. Department of Community Medicine, Vels Medical College and Hospital (VISTAS), Thiruvallur, Chennai, India

**Received:** 13 Aug 2025

**Accepted:** 19 Sep 2025

**Correspondence to:** Sivaanusuya SUDHAKARAN
E-mail: anusudhagaran@gmail.com

## 1. INTRODUCTION

Tobacco is the common term for any product that is prepared from the tobacco plant (cured leaves). It is an addictive substance that contains the stimulant alkaloid nicotine as well as harmala alkaloids, which can lead to tolerance and dependence. All smoking and smokeless forms of tobacco contain nicotine that causes addiction and health problems [1,2].

Globally, cigarette smoking is the second major cause of preventable deaths, the fourth most common risk factor for disease and the leading cause of preventable deaths in industrialized countries [3,4]. According to the WHO, there are nearly 6 million deaths every year due to tobacco usage, which is projected to rise to 8 million deaths annually by the year 2030, especially in developing countries [5, 6]. It also accounts for approximately 4.1% of Disability Adjusted Life Years (DALYs) lost each year [2,7].
In India, tobacco usage drives approximately 150 million people into poverty [8,9]. Tobacco is harmful for both the heart and the body, as it mainly causes death through heart disease and cancer, due to inhalation of poisonous chemicals such as cyanide, carbon monoxide, and carcinogens. Such inhalation leads to cardiovascular diseases, including myocardial infarction (heart attack), angina (chest pain), sudden cardiac death, as well as chronic obstructive pulmonary disease, exacerbation of asthma, osteoporosis and the development of cancer at multiple sites, namely the lungs, mouth, esophagus, pharynx, larynx, stomach, urinary bladder, gallbladder, penis and potentially other sites. Usage of tobacco in women causes infertility, earlier menopause and increased risk of cervical cancer and breast cancer [10]. During pregnancy, it increases the risk of ectopic pregnancy, placenta previa, abruptio placenta, spontaneous abortion, stillbirth and low-birth-weight in infants [11,12]. Inhaling secondhand smoke can cause lung cancer and heart disease. The percentages of exposure among adults were estimated at 38.7%, 30.2% and 7.4%, at home, in indoor workplaces and in restaurants, respectively [13,14].

The prevention of tobacco usage among young adults appears as the greatest opportunity for preventing noncommunicable diseases (NCD) [15]. Recognizing this, India has implemented many policy interventions, including bans on advertising and promoting tobacco, bans on smoking in public spaces and increased taxation on tobacco-related products. These measures have shown measurable success in reducing consumption.

According to the National Family Health Survey (NFHS-3) in 2005–06, the prevalence of adult smokeless tobacco use was found to be 36.9% and 9% in men and women, respectively [16]. According to the Global Adult Tobacco Survey (GATS-1) in 2009-2010, the prevalence of adult tobacco usage was reported as 24.3% for smoking and 32.9% for smokeless tobacco in men, whereas in the case of women it was 2.9% for smoking and 18.4% for smokeless tobacco [17]. According to the National Family Health Survey (NFHS-4) 2015, a survey of India Government conducted in 13 states showed the tobacco usage among men has fallen from 50% to 47% [18].

As of national health surveys, despite these advancements, higher tobacco use prevalence in rural populations remains a significant concern [19]. However, there is a scarcity of recent and community-based studies focusing on adult rural populations in specific districts. Therefore, the present study was undertaken to assess the prevalence and determinants of tobacco use among adults aged 18 years and above in rural areas of Kanyakumari district, Tamil Nadu.

## 2. PATIENTS, MATERIALS AND METHODS

The study is a community-based cross-sectional study where the prevalence of tobacco use among adult groups aged over 18 years in both genders, as well as the factors associated with tobacco use were studied in the Thiruvattar block area of Kanyakumari District. The study was realized from February 2019 to July 2021. As per the Global Adult Tobacco Survey (GATS) 2 (2016-2017) [14], in India, the prevalence of tobacco use was 28.6%. Based on this prevalence, the sample size was calculated using the following formula:

Sample size (n) = $Z_{\alpha}^{2}pq/d^{2}$, where: $Z_{\alpha} = 3.8416$, $p = 28.6$ (the prevalence of tobacco use in India according to GATS 2 is 28.6.%.), $q = 100$, $p = 100 - 28.6 = 71.4$, $d$ = relative error (20% of $p$) = $20\%$ of $28.6 = 5.72$.

By substituting the values in the above equation, $n = (1.96)^{2}*28.6*71.4/(5.72)^{2} = 239.76$ and is approximated to 250 sample size. Multi-stage random sampling was used. In the first stage, Kanyakumari District is divided into nine blocks. Based on the lot method, the Thiruvattar block (10 village panchayats and 6 town panchayats) area was selected. In the second stage, only the 5 village panchayats (Arivikkarai, Cherukode, Kumarankudy, Yettacode and Pechiparai) were selected by lottery method, and in the last stage, all the streets were listed out and allotted the numbers accordingly. Using this, five streets were selected randomly using a lot method, and 10 adults were included in the study from each street. The data collected from March 2019 to November 2019.

Both adult genders aged 18 years and above and residing in the study area for the last 6 months were included. Those who were not willing to participate and unable to respond due to hearing problems and those who were absent on three consecutive visits were excluded from the study. The study was initiated after obtaining the ethical clearance from the Institutional Research Committee and Institutional Human Ethics Committee. Face-to-face interviews were done among the participants. Study parameters were analyzed using IBM Statistical Package for Social Science Trial version 20.0.

## 3. RESULTS

A cross-sectional study conducted among 250 adult males and females in the Thiruvattar block revealed the demographic profiles of the participants as in Table 1. The study included 159 males (63.6%) with a mean age of 41.43 ± 12.32 years and 91 females (36.4%) with a mean age of 35.47 ± 11.43 years.
<table><caption>Table 1. Demographic profiles of the participants.</caption><thead><tr><th>Sno</th><th>Characteristics</th><th>Number(n)</th><th>Percentages (%)</th></tr></thead><tbody><tr><td></td><td>SEX DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>Males</td><td>159</td><td>63.6%</td></tr><tr><td></td><td>Females</td><td>91</td><td>36.4%</td></tr><tr><td>2.</td><td>AGE GROUP DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>18-30 years</td><td>77</td><td>30.8%</td></tr><tr><td></td><td>31-40 years</td><td>57</td><td>22.8%</td></tr><tr><td></td><td>41-50 years</td><td>66</td><td>26.4%</td></tr><tr><td></td><td>51-60 years</td><td>39</td><td>15.6%</td></tr><tr><td></td><td>Above 60 years</td><td>11</td><td>4.4%</td></tr><tr><td>3.</td><td>Religious DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>Hindu</td><td>112</td><td>44.8%</td></tr><tr><td></td><td>Muslim</td><td>5</td><td>2%</td></tr><tr><td></td><td>Christian</td><td>133</td><td>53.2%</td></tr><tr><td>4.</td><td>Marital status DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>Married</td><td>184</td><td>73.6%</td></tr><tr><td></td><td>Unmarried</td><td>55</td><td>22%</td></tr><tr><td></td><td>Widowed/divorced</td><td>11</td><td>4.4%</td></tr><tr><td>5.</td><td>Family type DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>Nuclear family</td><td>212</td><td>84.8%</td></tr><tr><td></td><td>Three generation family</td><td>35</td><td>14%</td></tr><tr><td></td><td>Joint family</td><td>3</td><td>1.2%</td></tr><tr><td>6.</td><td>Educational status DISTRIBUTION</td><td></td><td></td></tr><tr><td></td><td>Illiterate</td><td>12</td><td>4.8%</td></tr><tr><td></td><td>Primary schooling</td><td>35</td><td>14%</td></tr><tr><td></td><td>Middle schooling</td><td>54</td><td>21.6%</td></tr><tr><td></td><td>High schooling</td><td>51</td><td>20.4%</td></tr><tr><td></td><td>Inter diploma</td><td>40</td><td>16%</td></tr><tr><td></td><td>Graduate and professional</td><td>58</td><td>23.2%</td></tr><tr><td>7.</td><td>Socio economic status distribution (MODIFIED BG PRASAD'S SCALE)</td><td></td><td></td></tr><tr><td></td><td>Class-I</td><td>8</td><td>3.2%</td></tr><tr><td></td><td>Class-II</td><td>10</td><td>4%</td></tr><tr><td></td><td>Class-III</td><td>97</td><td>38.8%</td></tr><tr><td></td><td>Class-IV</td><td>135</td><td>54%</td></tr></tbody></table>

## Prevalence of tobacco usage:

As described in Table 2, the study found that 22.4% were current tobacco users; among them, 28.57% used smokeless forms. The mean age of initiation was 18.03 ± 2.922 years, and the average duration of usage was 25.20 ± 11.605 years. Stress played a significant role in initiating tobacco habits, with 25.4% citing stress with pressure and 20.62% stress with enjoyment. Among current users, 87.5% consumed tobacco in public places, while 57.14% had quit after learning about the associated health risks. Secondhand smoke exposure was reported in homes (23.2%), workplaces (15.2%) and public areas (67.6%). Notably, 73.2% of the participants supported banning tobacco in public places, and 70.8% were aware of its harmful effects, mainly through cinema (65.4%) and mobile sources (58.6%). Despite 87.2% of participants recognizing tobacco as addictive, 42.2% felt it was too difficult to quit, even with high awareness. Additionally, 38.4% of participants believed tobacco use helped them make friends, 12.4% thought it enhanced attractiveness, 82% felt it induced relaxation and 33.6% perceived smoking as beneficial for bowel movements.

## Assessment of factors associated with tobacco use

Factors that are associated with tobacco use are described in tables 3 and 4. Current tobacco use by gender was found to be statistically significant using Fisher's exact test with a value of 41.302, df-1 and p value <0.001 (table 3). Tobacco use by type (somking, smokless, both) was significant as well: Fisher's value 33.671, df-3 and p-value < 0.001 (table 4). Tobacco use was found to be higher among the age group > 41 years, and it was statistically significant with a p-value of 0.033, df-1 and chi square value of 4.555. Among the study
<table><caption>Table 2. Prevalence on tobacco usage.</caption><thead><tr><th>TOBACCO USAGE</th><th>FREQUENCY(N)</th><th>PERCENTAGE (%)</th></tr></thead><tbody><tr><td>Never user</td><td>187</td><td>74.8%</td></tr><tr><td>Current user</td><td>56</td><td>22.4%</td></tr><tr><td>Past user</td><td>7</td><td>2.8%</td></tr><tr><td colspan="3">STATUS OF USERS</td></tr><tr><td>MODE OF TOBACCO FORMS</td><td>CURRENT USER</td><td>PAST USER</td></tr><tr><td>Smokers</td><td>19(33.93%)</td><td>7(100%)</td></tr><tr><td>Smokeless</td><td>16(28.57%)</td><td>0</td></tr><tr><td>Both users</td><td>21(37.5%)</td><td>0</td></tr><tr><td>STATUS OF USERS</td><td>Types of tobacco</td><td>N(%)</td></tr><tr><td>Smokers(40)</td><td>Cigarette</td><td>23(57.5%)</td></tr><tr><td>Smokeless(37)</td><td>Beedi</td><td>17(42.5%)</td></tr><tr><td>Smokeless(37)</td><td>Chewers</td><td>23(62.16%)</td></tr><tr><td>Smokeless(37)</td><td>Snuff users</td><td>14(37.84%)</td></tr><tr><td>REASON FOR INITIATION</td><td>FREQUENCY (N)</td><td>PERCENTAGE (%)</td></tr><tr><td>Enjoyment</td><td>9</td><td>14.29%</td></tr><tr><td>Peer pressure</td><td>8</td><td>12.7%</td></tr><tr><td>Peer pressure + Enjoyment</td><td>12</td><td>19.05%</td></tr><tr><td>Religious / Festive occasions</td><td>5</td><td>7.94%</td></tr><tr><td>Stress + Enjoyment</td><td>13</td><td>20.62</td></tr><tr><td>Stress + Peer pressure</td><td>16</td><td>25.4%</td></tr><tr><td colspan="3">CURRENT USERS FREQUENCY (%)</td></tr><tr><td>PLACES OF USAGE</td><td>FREQUENCY (%)</td><td>PAST USERS</td></tr><tr><td>Home</td><td>30(53.57%)</td><td>5(71.43%)</td></tr><tr><td>Work places</td><td>28(50%)</td><td>2(28.57%)</td></tr><tr><td>Public places</td><td>49(87.5%)</td><td>7(100)</td></tr><tr><td>REASON FOR QUITTING</td><td>FREQUENCY(N)</td><td>PERCENTAGE (%)</td></tr><tr><td>Economic burden</td><td>2</td><td>28.57%</td></tr><tr><td>Known ill effects</td><td>1</td><td>14.29%</td></tr><tr><td>Development of diseases</td><td>4</td><td>57.14%</td></tr><tr><td>AWARENESS OBTAINED FROM</td><td>FREQUENCY (N)</td><td>PERCENTAGE (%)</td></tr><tr><td>News paper</td><td>66</td><td>26.4%</td></tr><tr><td>TV</td><td>118</td><td>47.2%</td></tr><tr><td>Mobile</td><td>147</td><td>58.8%</td></tr><tr><td>Radio</td><td>30</td><td>12%</td></tr><tr><td>Public vehicle</td><td>26</td><td>10.4%</td></tr><tr><td>Public wall</td><td>46</td><td>18.4%</td></tr><tr><td>Cinema</td><td>163</td><td>65.2%</td></tr><tr><td>Posters</td><td>55</td><td>22%</td></tr></tbody></table>

subjects, tobacco users in smoke form and smokeless form were found to be high in the age group >41 years, and that was statistically significant using the Chi-square test with p-value 0.014, df- 3, Chi square value 10.56. Usage of both smoking and smokeless forms of tobacco was found to be high among literates, and that was statistically significant with a p-value of 0.037, df- 1 and Fisher's exact value of 8.771. Based on the occupation, tobacco use was found to be more common among semi-skilled to unemployed persons, and that was statistically highly significant using Chi square test with a p-value of 0.002, df- 1, and a Chi-square value of 9.698. Smoking-type tobacco usage was found to be higher among semi-skilled, unskilled and unemployed persons and was statistically highly significant using Chi square test with p-value 0.008, df- 3, and Chi-square value of 11.938. There was a highly statistically significant association found between tobacco use and socioeconomic status with a p-value of 0.000, df-1, Chi square value of 17.540. There was a high statistically significant association found between the type of tobacco use and the socioeconomic status with a p-value of 0.000, df-3, and Fisher's exact value of 18.890. Variables that were found to be significantly associated with current tobacco usage in the chi-square test were gender, age group, occupation and socioeconomic status.
<table><caption>**Table 3.** Tobacco Use According to Gender, Age Group, Occupation and Socioeconomic Status.</caption><thead><tr><th>Gender/Tobacco use</th><th>Tobacco users</th><th>Tobacco Non users</th><th>df</th><th>P value</th><th>Fisher's exact value</th></tr></thead><tbody><tr><td>MALE</td><td>56</td><td>103</td><td></td><td></td><td></td></tr><tr><td>FEMALE</td><td>0</td><td>91</td><td>1</td><td>0.000*</td><td>41.137</td></tr><tr><td></td><td colspan="2">Age group/Tobacco use</td><td></td><td></td><td></td></tr><tr><td>&lt;40 years</td><td>23</td><td>111</td><td>1</td><td>0.033*</td><td>4.555</td></tr><tr><td>&gt;41 years</td><td>33</td><td>83</td><td></td><td></td><td></td></tr><tr><td></td><td colspan="2">Occupation/Tobacco use</td><td></td><td></td><td></td></tr><tr><td>Professional to skilled workers</td><td>25</td><td>131</td><td></td><td></td><td></td></tr><tr><td>Semi-skilled to unemployed</td><td>31</td><td>63</td><td>1</td><td>0.002*</td><td>9.698</td></tr><tr><td></td><td colspan="2">Socio-economic status /Tobacco use</td><td></td><td></td><td></td></tr><tr><td>Upper to Middle class</td><td>12</td><td>103</td><td></td><td></td><td></td></tr><tr><td>Lower middle to Lower class</td><td>44</td><td>91</td><td>1</td><td>0.000*</td><td>17.540</td></tr></tbody></table>

<table><caption>**Table 4.** Type of tobacco used according to gender, age group, marital status, education.</caption><thead><tr><th>Gender/Tobacco type</th><th>Non smokers</th><th>Smoking tobaccos</th><th>Smokeless tobaccos</th><th>Both</th><th>Df</th><th>P value</th><th>Fisher's exact value</th></tr></thead><tbody><tr><td>MALE</td><td>103</td><td>19</td><td>16</td><td>21</td><td></td><td></td><td></td></tr><tr><td>FEMALE</td><td>91</td><td>0</td><td>0</td><td>0</td><td>3</td><td>0.000*</td><td>33.671</td></tr><tr><td>Age group / Tobacco type</td><td>Smoking tobacco</td><td>Smokeless tobaccos</td><td>Both</td><td>df</td><td>P value</td><td>Chi square value</td><td></td></tr><tr><td>&lt;40 years</td><td>6</td><td>4</td><td>13</td><td>2</td><td>0.045*</td><td>6.233</td><td></td></tr><tr><td>&gt;41 years</td><td>13</td><td>12</td><td>8</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td colspan="2">Marital status/Tobacco type</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Unmarried</td><td>1</td><td>1</td><td>7</td><td>2</td><td>0.026*</td><td>7.325</td><td></td></tr><tr><td>Married/Separated</td><td>18</td><td>15</td><td>14</td><td></td><td></td><td></td><td></td></tr><tr><td></td><td colspan="2">Education /Tobacco type</td><td></td><td></td><td></td><td></td><td></td></tr><tr><td>Illiterates/up to Middle school</td><td>12</td><td>3</td><td>6</td><td>2</td><td>0.015*</td><td>8.517</td><td></td></tr><tr><td>High school and higher</td><td>7</td><td>13</td><td>15</td><td></td><td></td><td></td><td></td></tr></tbody></table>

## 4. DISCUSSION

This study was conducted among adults in rural areas of Kanyakumari district, where the prevalence of tobacco use was found to be 22.4%. This finding was similar to studies conducted by Rani M [19] (National Survey 1998–1999, India), Imtiaz D [20] (Uttarakhand, 2013), Chockalingam K [3] (Chennai, 2009–2012) and Praveen Lal CJ [21](Kerala). However, there were significant variations when compared with several other studies. The prevalence of tobacco use ranged from 40% to 50% in studies conducted by Bala DV [22] (Gujarat, 2006), Divyang Kumar N [23] (2016), Anand A [24] (2007), Bhavya B [2] (Karnataka, 2012), Christopher J Rogers [75] (US), Jeeragyal DP [54] (Andhra, 2012–14), Jindal SK [25] (Chandigarh, 2006), Konduru RK [26] (Thiruvallur, 2008), Subramanian SV [27] (India, 1998–99), Das R [28] (Tripura) and Mukherjee K [29] (Mumbai). In contrast, studies by Sinha DN [30] (Bihar, 2000) and Aryal U [31] (Kathmandu) reported even higher prevalence rates, exceeding 70%. And in our study, females were nonsmokers; either they are reluctant to disclose their habits of tobacco use during data collection in view of stigma, or it may be the true low prevalence in our area. A few notable studies recorded very low prevalence rates, ranging from 10% to 20%, such as those conducted by Gaja Lakshmi CV [32] (South India), Owolabi EO [33] (South Africa, 2017), Waweru P [34] (South India), Gupta RK [12], Ahamed RS [35] (Aligarh, 2009), Kumar S [36] (Lucknow, 2011) and Berg CJ [37] (2011). Extremely low prevalence (<5%) was observed in studies by Singh V [38] (Jaipur), Kumar R [39] (Delhi), Devi LJ [40] (Manipur), Fotedar S [41] (Himachal Pradesh), Bridget K Ambrose [42] (US) and Namratha Kulkarni [43].

In the present study, a majority of current tobacco users (37.5%) used both smoke and smokeless forms, and smokers (33.93%) outnumbered smokeless users (28.57%). Studies by Bhavya B[2] (Karnataka, 2012), Christopher J Rogers [44] (US) and Imtiaz D[20]

<footnote>* P < 0.05 is statistically significant.</footnote>

<footnote>* P < 0.05 is statistically significant.</footnote>
(Uttarakhand) found smoking prevalence to be below 17%. A higher prevalence (>50%) of smoked tobacco compared to smokeless forms was noted in studies by Sakore DN [15] Kapoor SK [45], Basu D [46], Singhi S [47], Madan KPD [48] and Lim KH [49], attributed to easy addiction, low cost, portability and social enjoyment. Conversely, smokeless tobacco usage (> 45%) was higher in studies by Das R [28], Dixit AM [8], Makwana NR [50] and Taran SJ [51], often due to lower cost, discretion in public usage, cultural acceptance and lack of warning labels.

Among current smokers in this study, cigar users (57.5%) were more prevalent than beedi users (42.5%), consistent with Chockalingam K [3]. However, studies by Dixit AM [8], Gupta RK [12], Imtiaz D [20] and Jindal SK [25] found beedis more popular due to their affordability and availability. Das RS [28] study in Northern states noted widespread use of pan with tobacco, Gul, Gutka, Khaini and Hookah. The mean age of initiation for tobacco use was 18±2 years. Similar initiation ages (18–35 years) were found in studies by Gupta RK [12], Santhana Krishnan I [52] and the Global Adult Tobacco Survey-2 [14]. Other studies by Imtiaz D [20] (Uttarakhand, 2013), Nisar N [53] (Karachi, 2005) and Mishra GA [54] reported initiation before 20 years, indicating adverse effects on school and college education.

Education plays a vital role in determining tobacco use patterns. In this study, tobacco use was higher among individuals with higher education levels, possibly due to increased social interactions. However, studies by Garg A [55] (Delhi, 2007), Dixit AM [8] (Jaipur), Bhasker S [56] (Delhi), Chhabra SK [57], Prabhakar B [58], Mukherjee K [29] (Mumbai) and Rani M [19] (National Survey—India) showed an inverse relationship, with higher tobacco use among the less educated due to poor awareness of health risks. Our study also found a significant association between lower socioeconomic status and tobacco use, aligning with findings from Bhavya B [2] (Karnataka, 2012), Bala DV [22] (Gujarat, 2006), Ahamed RS [35] (Aligarh, 2009), Garg A [55] (Delhi, 2007) and Dixit AM [8] (Jaipur), highlighting how poverty and tobacco usage form a vicious cycle.

Further associations were observed between tobacco use and gender, education, occupation and socioeconomic status. Studies by Bhavya B [2], Bala DV [22], Owolabi EO [33] and Chulasiri MP [59] found similar associations, emphasizing the roles of literacy, occupation and socio-cultural factors. Christopher J. Rogers [44] (US) linked tobacco use with stress and financial burden, Imtiaz D [20] (Uttarakhand) with age groups, Chockalingam K [3] (Chennai) with geographic location, and Parashar M [60] (Delhi) with marital status, migrant status, income and family type. Tobacco consumption not only impacts users but also harms families through secondhand smoke exposure, particularly among impoverished groups. Even minimal spending on tobacco can exacerbate poverty, leading to poor nutrition, decreased healthcare-seeking behavior and malnutrition.

The present study provides important insights into tobacco habits and awareness among adults, offering valuable guidance for policymakers and public health officials. It also emphasizes a holistic approach to tobacco cessation, shifting from individual-centered strategies to broader community-wide interventions. This study is confined within a specific geographical area and only to that demographic population; hence, the findings cannot reflect the regional or the national averages.

## 5. CONCLUSIONS AND RECOMMENDATIONS

Despite adequate awareness of health hazards, prevalence of tobacco use was slightly higher among early adult life, married males, nuclear families, and skilled semi-skilled workers. Currently tobacco-free and tobacco incorporated pan masala are highly used among college students and younger age adults which is an innocuous habit. Hence it is suggested that anti-tobacco measures and awareness creation should be initiated early in life as primary prevention, and also among those who are unwilling to quit and unaware of its harmful effects. Common beliefs about initiation were found to be stress, peer pressure, and enjoyment; therefore, FGD (focused group discussions) can be targeted among rural populations and school candidates may result in quitting at their early stages. Each parent plays a major role in that they need to take care of the adult to inspect his regular activities and their friend's circle, which helps to bring them back to normal by explaining the good and bad aspects of tobacco and other substance abuse. On considering all the above knowledge, awareness and legislative measures, one should have their own self-control to quit tobacco use and have to take major steps in sorting out life-threatening acts and poverty. There should be strong policies to ban tobacco use at public places, near schools, temples, workplaces, hospitals and restaurants. And the government also should increase the taxes on tobacco products and increase the price of the products so that they are not easily affordable to school and college students and poor people. There should be surveillance of nicotine content in the tobacco products at both the manufacturer and consumer levels. There should not be recreational or usage of e-cigarettes in view of tobacco cessation.

**Competing interests:** The authors declare that they have no competing interest.

**Funding:** This research received no external funding.
REFERENCES

1. Rudgley R. Tobacco: from The Encyclopedia of Psycho active substances. Biopsychiatry. Boston: Little, Brown and Company; 1998.

2. Bhavya B, Nisha C, Ankit S, Joseph EN, Anusha BK, Omkar P, et al. Tobacco use among adults and its associated factors in a rural area in Karnataka, India. J Hum Health. 2015.

3. Chockalingam K, Vedhachalam C, Rangasamy S, Sekar G, Adinarayanan S, Swaminathan S, et al. Prevalence of tobacco use in urban, semi urban and rural areas in and around Chennai, India. PLoS One. 2013;8(10):e76005. doi:10.1371/journal.pone.0076005

4. Guindon GE, Boisclair D. Past, current and future trends in tobacco use. Washington DC: The World Bank; 2003.

5. Singh A, Ladusingh L. Prevalence and determinants of tobacco use in India: evidence from recent Global Adult Tobacco Survey data. PLoS One. 2014;9(12):e114073. doi:10.1371/journal.pone.0114073

6. World Health Organization. WHO report on the global tobacco epidemic, 2008: The MPOWER package. Geneva: World Health Organization; 2008.

7. World Health Organization. Global burden of disease [Internet]. [cited 2015 Mar 16]. Available from: http://www.who.int/substance_abuse/facts/global_burden/en

8. Dixit AM, Jain PK, Agarwal R, Gupta S, Shukla SK, Rani V. Prevalence and pattern of tobacco use in rural community of Jaipur, Rajasthan (India): a cross sectional study. Natl J Community Med. 2015;6(1):16-20.

9. United Nations. Prevention and control of noncommunicable diseases: Report of the Secretary General. A/66/83. New York: UN; 2011 [cited 2013 Mar 12]. Available from: http://www.un.org/ga/search/view_doc.asp?symbol=A/66/83&Lang=E

10. Jensen KE, Schmiedel S, Frederiksen K, Norrild B, Iftner T, Kjaer SK. Risk for cervical intraepithelial neoplasia grade 3 or worse in relation to smoking among women with persistent human papillomavirus infection. Cancer Epidemiol Biomarkers Prev. 2012;21(11):1949-55. doi:10.1158/1055-9965.EPI-12-0663

11. Mackay J. The global tobacco epidemic: the next 25 years. Public Health Rep. 1998;113(1):14-21.

12. Gupta RK, Verma AK, Shora TN, Kumari R, Langer B. Tobacco abuse: prevalence, patterns and awareness among rural adults-a population based study. JK Sci. 2016;18(4):201-5.

13. Ministry of Health and Family Welfare, Government of India. Global adult tobacco survey: India report 2009-10. New Delhi: Ministry of Health and Family Welfare; 2010.

14. Ministry of Health and Family Welfare, Government of India. Global adult tobacco survey: India report 2016-17. New Delhi: Ministry of Health and Family Welfare; 2017.

15. Sakore DN, Parande MA, Tapare VS, Bhattacharya S. Knowledge, attitude and practice of tobacco consumption among male college students of a rural area of Pune, Maharashtra. Int J Community Med Public Health. 2017;4(9):3455-60. doi:10.18203/2394-6040.ijcmph20173654

16. International Institute for Population Sciences. National Family Health Survey (NFHS-3), 2005-2006: India: Volume I. Mumbai: IIPS; 2007.

17. Bhawna G. Burden of smoked and smokeless tobacco consumption in India-results from the global adult tobacco survey India (GATS-India)-2009-2010. Asian Pac J Cancer Prev. 2013;14(5):3323-9. doi:10.7314/apjcp.2013.14.5.3323

18. International Institute for Population Sciences. National Family Health Survey (NFHS-4), 2015-2016: India. Mumbai: IIPS; 2017 [cited 2016 Feb 23]. Available from: http://www.rchiips.org/NFHS/factsheet_NFHS-4.shtml

19. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control. 2003;12(4):e4. doi:10.1136/tc.12.4.e4

20. Imtiaz D, Kandpal SD, Juyal R, Shrotriya VP, Singh AK. A study on prevalence and pattern of smoking among rural population in Dehradun district of Uttarakhand. Natl J Community Med. 2014;5(4):440-3.

21. PL CJ, Nair SB. Socio-economic influence on tobacco use among male youth in Kerala.

22. Bala DV, Bodiwala IN, Patel DD, Shah PM. Epidemiological determinants of tobacco use in Gujarat state, India. Indian J Community Med. 2006;31(3):173-6.

23. Patel DN, Koyyalamudi VB, Purani SK, Soni ST, Kavishwar AB. A cross sectional study of smoking among youth population. Int J Biomed Adv Res. 2016;7(12):574-7.

24. Anand A, Roy N. Prevalence and determinants of co-use of alcohol and tobacco among men in working age group (18-59 years) in India. Epidemiol Biostat Public Health. 2016;13(1):e11531. doi:10.2427/11531

25. Jindal SK, Aggarwal AN, Chaudhry K, Chhabra SK, D'Souza GA, Gupta D, et al. Tobacco smoking in India: prevalence, quit-rates and respiratory morbidity. Indian J Chest Dis Allied Sci. 2006;48(1):37-42.

26. Konduru RK, Sathiyasekaran BW. A study on tobacco use among rural adults. J Evol Med Dent Sci. 2013;2(15):2493-502.

27. Subramanian SV, Nandy S, Kelly M, Gordon D, Smith GD. Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey. BMJ. 2004;328(7443):801-6. doi:10.1136/bmj.328.7443.801

28. Das R, Baidya S. Prevalence of tobacco use among rural women of Mohanpur Block, West Tripura district. Hindu. 2014;459:99-8.

29. Mukherjee K. Study on tobacco consumption patterns and its determinants in an urban slum in New Mumbai. Int J Epidemiol Res. 2015;2(4):164-71.

30. Sinha DN, Gupta PC, Pednekar MS. Tobacco use in a rural area of Bihar, India. Indian J Community Med. 2003;28(4):167-70.

31. Aryal UR, Deuba K, Subedi A, Shrestha R, Bhatta L. Prevalence and determinants of cigarette smoking among the college students of Kathmandu Valley. Asian J Med Sci. 2010;1(2):53-8.

32. Gajalakshmi V, Kanimozhi V, Mangala K, Warren CW. Tobacco survey among youth in South India. Asian Pac J Cancer Prev. 2004;5(3):273-8.
33. Owolabi EO, Goon DT, Adeniyi OV, Seekoe E, Adedokun AO. Prevalence and factors associated with tobacco use among adults attending selected healthcare facilities in Buffalo City Metropolitan Municipality, South Africa. S Afr Fam Pract. 2017;59(6):201-7. doi:10.1080/20786190.2017.1333788

34. Waweru P, Anderson R, Steel H, Venter WD, Murdoch D, Feldman C. The prevalence of smoking and the knowledge of smoking hazards and smoking cessation strategies among HIV positive patients in Johannesburg, South Africa. S Afr Med J. 2013;103(11):858-60. doi:10.7196/samj.7082

35. Ahamed RS, Ansari A. Pattern and prevalence of smoking in urban and rural areas of Aligarh. Glob Res Anal. 2013;2(10):195-6.

36. Kumar S, Dwivedi V, Pandey U, Bala N, Vasandani S, Singh K, et al. Tobacco use in Northern India-Part 1: the detailed habit. J Oral Biol Craniofac Res. 2011;1(1):24-30. doi:10.1016/S2212-4268(11)60006-0

37. 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. doi:10.1186/s12889-015-1816-3

38. Singh V, Gupta R. Prevalence of tobacco use and awareness of risks among school children in Jaipur. J Assoc Physicians India. 2006;54:609-12.

39. Kumar R, Singh A, Khushwah MA, Prakash S, Vijayan VK. A study of tobacco consumption among college students of university of Delhi, India. Indian J Prev Soc Med. 2010;41(3-4):198-202.

40. Devi LJ, Laishram J, Jayarani L, Devi NM, Ingudum D. Tobacco use among females in an urban community of Imphal West, Manipur. J Med Soc. 2014;28(1):11-2.

41. Fotedar S, Sogi GM, Fotedar V, Bhushan B, Singh B, Dahiya P, et al. Knowledge of, attitude towards, and prevalence of tobacco use among dental students in Himachal Pradesh State, India. Oral Health Dent Manag. 2013;12(2):73-9.

42. Ambrose BK, Rostron BL, Johnson SE, Portnoy DB, Apelberg BJ, Kaufman AR, et al. Perceptions of the relative harm of cigarettes and e-cigarettes among US youth. Am J Prev Med. 2014;47(2 Suppl 1):S53-60. doi:10.1016/j.amepre.2014.04.016

43. Kulkarni N, Shilpa K, Naik VA, Mallapur MD. Prevalence and acquisition of tobacco use among rural women in reproductive age group-a community based cross sectional study. Indian J Forensic Community Med. 2016;3(3):180-2.

44. Rogers CJ, Forster M, Unger JB. Ethnic variations in the relationship between multiple stress domains and use of several types of tobacco/nicotine products among a diverse sample of adults. Addict Behav Rep. 2018;7:96-102. doi:10.1016/j.abrep.2018.03.002

45. Kapoor SK, Anand K, Kumar G. Prevalence of tobacco use among school and college going adolescents of Haryana. Indian J Pediatr. 1995;62(4):461-6. doi:10.1007/BF02755067

46. Basu D, Jhirwal OP, Singh J, Kumar S. Inhalant abuse by adolescents: a new challenge for Indian physicians. Indian J Med Sci. 2004;58(6):245-9.

47. Singhi S, Broca JS, Mathur GM. Smoking behaviour of rural school boys. Indian Pediatr. 1987;24(8):655-9.

48. Kumar PM, Poorni S, Ramachandran S. Tobacco use among school children in Chennai city, India. Indian J Cancer. 2006;43(3):127-31.

49. Lim KH, Teh CH, Mohamed MH, Pan S, Ling MY, Yusoff MF, et al. Exposure to tobacco secondhand smoke and its associated factors among non-smoking adults in smoking-restricted and non-restricted areas: findings from a nationwide study in Malaysia. BMJ Open. 2018;8(1):e017203. doi:10.1136/bmjopen-2017-017203

50. Makwana NR, Shah VR, Yadav S. A study on prevalence of smoking and tobacco chewing among adolescents in rural areas of Jamnagar district, Gujarat state. J Med Sci Res. 2007;1(1):1-3.

51. Taran SJ, Taran R, Saroshe S, Bhandari V. A cross sectional study to assess the prevalence and awareness of tobacco consumption among school students in a cosmopolitan city of India. Int J Contemp Pediatr. 2016;3(1):86-91. doi:10.18203/2349-3291.ijcp20151619

52. Santhanakrishnan I, Kar SS. Prevalence of tobacco use among adults in Ramanathapuram village of Pondicherry. Int J Med Public Health. 2014;4(3):309-12. doi:10.4103/2230-8598.137747

53. Nisar N, Qadri MH, Fatima K, Perveen S. A community based study about knowledge and practices regarding tobacco consumption and passive smoking in Gadap Town, Karachi. J Pak Med Assoc. 2007;57(4):186-8.

54. Mishra GA, Kulkarni SV, Gupta SD, Shastri SS. Smokeless tobacco use in urban Indian women: prevalence and predictors. Indian J Med Paediatr Oncol. 2015;36(3):176-82. doi:10.4103/0971-5851.166676

55. Garg A, Singh MM, Gupta VK, Garg S, Daga MK, Saha R. Prevalence and correlates of tobacco smoking, awareness of hazards, and quitting behavior among persons aged 30 years or above in a resettlement colony of Delhi, India. Lung India. 2012;29(4):336-40. doi:10.4103/0970-2113.102817

56. Bhasker S, Bajpai V, Kumar V, Kant S. A study of factors impacting on the tobacco use patterns and tobacco-related behavior among the lower middle and lower classes in a resettlement colony of Delhi, India. Int J Med Public Health. 2015;5(2):173-6. doi:10.4103/2230-8598.153828

57. Chhabra SK, Rajpal S, Gupta R. Patterns of smoking in Delhi and comparison of chronic respiratory morbidity among beedi and cigarette smokers. Indian J Chest Dis Allied Sci. 2001;43(1):19-26.

58. Prabhakar B, Narake SS, Pednekar MS. Social disparities in tobacco use in India: the roles of occupation, education and gender. Indian J Cancer. 2012;49(4):401-9. doi:10.4103/0019-509X.107746

59. Chulasiri MP, Gunawardena NS, De Silva GA. Prevalence of smoking among adult males in Colombo District, Sri Lanka. Asian Pac J Health Sci. 2016;3(4S):73-80.

60. Parashar M, Dwivedi S, Singh M, Patavegar B, Bhardwaj M. Tobacco use behavior among construction site workers of Delhi, India. Int J Health Allied Sci. 2017;6(4):210-4. doi:10.4103/ijhas.IJHAS_71_17