|Year : 2016 | Volume
| Issue : 2 | Page : 33-38
Significance and determinants of tobacco use: A brief review
Fatma Mojtaba Alsaid Ahmed1, Syed Wali Peeran2
1 Department of Public Health Sciences, University of Miami, Miami, USA
2 Department of Periodontology and Oral Implantology, Faculty of Dentistry, Sebha University, Sebha, Libya
|Date of Web Publication||27-Jun-2016|
Fatma Mojtaba Alsaid Ahmed
Department of Public Health Sciences, University of Miami, Miami
Source of Support: None, Conflict of Interest: None
Tobacco is a plant product derived from a variety of plants belonging to the genus Nicotiana. The alkaloid nicotine present in the plant leafs is a stimulant and has an addictive effect. The tobacco plants have been historically grown and used for recreational purposes by the American local population. The dried tobacco leaves are consumed as chewing tobacco, snuff, and smoked in a variety of dispensations. Tobacco use (TU) has an adverse effect on various body systems and is a determinant for different diseases ranging from cancers to atherosclerosis. TU is a modifiable environmental risk factor for various diseases. Hence, with public health education and behavior modification, its burden can be reduced in a given society. Thus, the understanding of the incidence and prevalence of its use is necessary. This review attempts to sum up the significance and determinants of TU.
Keywords: Determinants, public health, smoking, tobacco, tobacco use
|How to cite this article:|
Ahmed FM, Peeran SW. Significance and determinants of tobacco use: A brief review. Dent Med Res 2016;4:33-8
| Introduction|| |
Tobacco use (TU) has an adverse effect on various body systems and is a determinant for different diseases ranging from cancers, cardiovascular diseases, respiratory diseases, reproductive problems, stroke, dementia to periodontal disease. ,,,, According to the World Health Organization, a billion people smoke tobacco. Moreover, TU comes with an excruciating public health cost of an early mortality of almost 50% of its users.  The deaths caused by TU are around 6 million people each year.  TU is a modifiable environmental risk factor for various diseases. Hence, with public health education and behavior modification, its burden can be reduced in a given society. Thus, the understanding of the incidence and prevalence of its use is necessary. A search in PubMed is planned to be done with different MeSH indicating the significance and determinants of TU in North Africa. This review attempts to sum up the prevalence of its use and determinants.
Tobacco is smoked as cigarettes, cigars, beedies, and waterpipe tobacco. The smokeless forms of TU are snuff, chewing tobacco including pan masala, gutka, and as a dentifrice. 
| Prevalence and significance of tobacco use|| |
In the US, 16.8% of 18 years or older adults are current cigarette smokers. Thus, in the US alone, there are an estimated 40 million current smokers.  China is the home to the world's largest population of smokers with 350 million smokers in 2012.  India is the second largest consumer of tobacco. It is home to 275 million TU which is more than the present day population of Western Europe. It also comprises 164 million smokeless TU, 69 million exclusive smokers, and 42 million dual users. ,, An early mortality of 450 million is expected with the current smoking trends between 2000 and 2050 worldwide. 
Determinants of tobacco use
Different individuals show a different pattern of susceptibility of TU. It depends on a myriad of factors. The following are the determinants of TU using an ecological model.
The global trends of smoking and TU show a significant difference between their use among men and women. Globally, smoking in men is prevalent manifolds than in women. However, the prevalence of smoking is similar in developed countries among both the genders. , A significant amount of published literature shows that men and women differ in their smoking behaviors. The pattern of smoking among women includes fewer per day use of cigarettes, use of lower nicotine-containing cigarettes, and lighter inhalation of smoke when compared to men.  These differences could be attributed to the differences prevalent worldwide in the levels of employment among the females consequently economic independence, gender-related norms and expectations prevalent in the different cultures and societies and concern about beauty and health.  This difference has a public health bearing. TU was responsible for 24% of all male deaths and 7% of all female deaths, rising to over 40% in men in some former socialist economies and 17% in women in the USA.  It is also interesting to note that in some developing countries where smokeless tobacco is used. The trends in its use are similar between both the genders, whereas smoking is relatively less common in females. , The preference of the mode of TU also differs globally. It was found that Indian females prefer smokeless tobacco, , whereas Saudi girls prefer smoking. 
The rates of regular TU are higher in older individuals. However, the primary initiation of its use and establishment take place in adolescence. An overwhelming majority of cigarette smokers first tried smoking by 18 years of age. , In 2014, the TU among high school students and middle school students in the US was at 24.6% and 7.7%, respectively. Recent data from 2011 to 2015 show a decline in smoking among youths in the US, whereas the use of other types of tobacco has increased.  The use of tobacco has serious public health consequences. A recent population-based survey showed that male young current smokers had a predilection for head and neck cancers.  An initiation of smoking at 16 years or earlier more than doubles the risk of future symptomatic peripheral arterial occlusive disease regardless of the amount of exposure to cigarette smoking. 
In a study among young adults in the US, it was found that higher levels of TU are seen for those with lower education. They found that those with a Bachelor's degree or greater were significantly less likely to use tobacco products compared to those with some college education. Those with less than a high school education had a two-fold increase in cigarette-only use and dual use compared to those with some college education. This pattern was similar for cigarette-only use among those with a high school education compared to some college education.  In a national multilevel cross-sectional survey analysis, they found that individuals with no education were 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. Increasing years of education people were less inclined to TU. Education is one of the most important protective factors against TU. ,,,,,,
Race and ethnicity have a varying effect on the prevalence of TU. Among the African-Americans in the US, the youths are less likely to use tobacco than others.  TU among them increases during late adolescence and early adulthood.  It is also worth noticing that daily smokers among the African-Americans are less likely to quit smoking than others.  In various states in the US, among women, a gradient exists, with Hispanic women smoking least, followed by black women, and white women smoking the most. Moreover, among men, Hispanic men display the lowest smoking prevalence, followed by white men and black men with approximately comparable smoking prevalence.  Hence, being Hispanic could be a protective factor against TU. In a study of analyzing data from 1056 African-American 8 th and 10 th graders, the authors found that the strongest predictors of smoking were a low academic achievement, peer drug use, and early substance use (individual domain). Also being in the 10 th grade was a significant predictor. These differences in TU among different races could also be due to the difference in marketing pattern. Menthol-flavored cigarettes are marketed in urban neighborhoods and areas with more black residents. There are more inducements due to differences in store types to start and continue smoking in lower-income neighborhoods and in areas with more black residents.  In a study of the national survey in India, it was found that among the four-tier Indian caste system, the scheduled tribes and scheduled castes, who formed the lowest strata, were more likely to consume tobacco than other caste groups. 
| Genetic factors|| |
Genetic vulnerability plays a role in who starts smoking, who develops nicotine dependence, and who succeeds with particular approaches to quitting.  Twin and family studies have shown that susceptibility of an individual to be addicted to nicotine is determined by the interplay of various genes. These multiple genes define the production, transmission, and metabolization of neurotransmitters, the availability of their receptors, and the rapidity of nicotine metabolism. 
| Psychological factors|| |
The available scientific evidence links various mental disorders and conditions with TU. Individuals with depression, anxiety disorders, and severe mental disorders such as schizophrenia, bipolar disorders, substance use disorders, personality disorders, risk of panic attack, and agoraphobia have been documented to have higher rates of TU and nicotine dependence. ,,,,
Nicotine use intertwined with various addictions. For example, alcohol consumption increases nicotine consumption and the rewarding effects of nicotine.  In a recent systematic review, it was found that smoking rates among people in addiction treatment were more than double of nonaddicts with similar demographic characteristics.  Substance abuse such as opioid addiction and alcohol addiction are risk factors for smoking, worse smoking behavior, and for unsuccessful quitting attempts of smoking. ,
Dual TU is the use of more than one form of tobacco. It was found to be higher among those who fair economically better.  In a study involving Indian Households, it was found that those who were among the lowest fifth of a standard of living index were 2.54 times more likely to consume tobacco than those in the highest fifth.  In a study involving individuals from India, it was found that those in the lower socioeconomic group are 8-10 times more likely to smoke bidis and consequently are at a higher risk of oropharyngeal and lung cancer.  It was also noticed that the initiation of TU among poor people was earlier and use of smokeless tobacco increased with poverty.  In an analysis of Northern Plain Native Americans in the US, poverty was found to be significant predictors of smoking.  In Brazil, the smokers had a statistically lower per capita income than nonsmokers.  Tobacco marketing is also greater in neighborhoods with lower income.  Thus, a general pattern among various studies indicates that poverty is a risk factor for TU.
| Microsystem and macrosystem factors|| |
In the family microsystem, the parent-youth relationship and families are significant determinants of TU. Children of parents with histories of alcohol addiction have higher rates of nicotine addiction. Such a pattern is noticeable even among family members who are not dependent on alcohol.  In a study in the US, they found that family risk factors included favorable parental attitudes to antisocial behavior and parental attitudes favorable to alcohol, cigarette, and marijuana use.  In a survey among 5150 female students in Jeddah, KSA, they found that the prevalence of ever cigarette smoking was significantly higher among the respondents who reported living with other than their parents, and higher water pipe smoking rate was found among the respondents who live with single mothers. 
The affiliation of adolescents with drug-using peers is a risk factor for TU and other addictive substances. , In adolescents, the presence of friends, who are smokers, leads to a higher prevalence of smoking among them. 
A number of studies have suggested that the wider introduction and enforcement of comprehensive school smoking regulations reduce the prevalence of smoking and future intent to smoke among school goers. , In an another study, increasing school rewards for prosocial involvement was found to be a protective factor for smoking.  In a study among middle-school students in Saudi Arabia, help and support from family, friends, and teachers and better school performance were found to be protective factors for TU. 
In a study in the US, it was found that nonsmokers were more likely to be individuals involved in religious activities such as prayer, Bible study, and regular church attendance.  In an another study in Malaysia, they found that a significant proportion of nonsmokers believed that Islam prohibits smoking, and the results also showed positive influences of Islamic beliefs on the nonsmokers.  The results were similar to that of Thailand where the majority of Muslims and the Buddhists believed that their religion discourages smoking.  In a preliminary study in Western China, they found a strong inverse relationship between religiosity in Chinese Muslim men and current smoking.  Hence, religiosity can be a protective factor among different population and could be used in faith-based interventions.
Media communications have an important role in imparting knowledge and modifying attitudes and behavior relating to TU.  On one hand, the campaigns against TU if regularly broadcasted through the mass media are decisive in reducing smoking prevalence among the population.  On the contrary, exposure to the advertisement of TU on TV, movies, video games, and other advertising modes is a risk factor for TU, especially among the youths. 
Some studies have reported a positive effect of restrictions and legislative bans on reducing TU. , A recent Cochrane review revealed a consistent evidence of a positive impact of national smoking bans on reductions in TU. It revealed that the bans improved cardiovascular health outcomes and reduced mortality for associated smoking-related illnesses. However, the evidence of an impact of legislative bans on smoking prevalence and tobacco consumption remained inconsistent. 
| Conclusion|| |
The use of tobacco is a public health problem of huge proportions. In addition, tobacco is the primary cause of many preventable diseases such as lung cancer and cardiac diseases. These adverse health effects are linked to the economical costs incurred by the diseases. There are many determinants of the TU which can be a risk factor or protective factors. Any intervention planned to reduce TU should target the risk factors to eliminate the TU in a given population. Further research is necessary to know the determinants of TU in different population worldwide.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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