The study was conducted from July to November 2015, among current SLT users visiting Department of Oral Medicine and Radiology, Manipal College of Dental Sciences (MCODS), Manipal University, Mangalore, Karnataka, India. Ethical clearance was obtained from the Institution Ethics Committee prior to commencement of the study. Patients visiting Department of Oral Medicine and Radiology who were current SLT users (since 30 days) were invited to take part in the study after explaining purpose of the research. Inclusion criteria included current SLT users and patients who were willing to participate in the study. Exclusion criteria included occasional users of SLT. A cross-sectional study design was employed in the present study. A structured, pretested, self-administered questionnaire was employed for the present study. The items for the questionnaire were selected by theory, observation, research and expert opinion [21]. A pilot study with 53 subjects was conducted prior to the start of the main study. Face validity of the questionnaire was assessed by giving it to experts. Internal consistency of the questionnaire was assessed by administering it to 53 patients. Crohnbach’s alpha and split half reliability of the questionnaire were employed to assess reliability of the questionnaire. The final questionnaire comprised of 78 items focusing on the knowledge (18), attitude (12), worksite practices (8), barriers (18), and, SLT usage and its cessation related practices (22) of the current SLT users. Demographic details such as age, sex, education, occupation, income, marital status and religion were also collected. Socio-economic status of the study participants was classified using Kuppuswamy scale [22,23].

A total of 18 questions were used to assess the knowledge of the study subjects with respect to safety of SLT as compared to smoking tobacco; injurious and addictive nature of SLT; conditions associated with SLT; effect of duration of SLT usage on its detrimental effects and quitting; effect of maternal tobacco usage on fetus; impact of quitting SLT usage on one’s health. The possible range of score for knowledge domain was 0-18, scored as 0 or 1 depending on the appropriateness of the answer.

Attitude of the study subjects was evaluated employing 12 items focusing on selling of tobacco to children; price, health warnings, advertisement of tobacco products; banning and implementation issues; quitting SLT usage. A 5 point Likert scale with the options of ‘strongly agree’, ‘agree’, ‘unsure’, ‘disagree’ and ‘strongly disagree’ was used with the possible score in range of 12-60.

Worksite related practices towards SLT use and its cessation were gauged using 8 items with a possible score range of 0-8. Each item was scored as 0 or 1 depending on the accuracy of the answer. This part of the questionnaire enquired about environmental and peer influences on tobacco use and its cessation; selling of tobacco in and around workplace; health education programs conducted at workplace.

Various factors which might negatively influence tobacco cessation were focused in the barrier domain comprising of 18 items which enquired about, if subject enjoys and craves for tobacco; if tobacco acts as a stress buster and relieves boredom; weight gain, fear of losing friends; not succeeding in quitting and withdrawal issues associated with tobacco cessation; peer and social pressure and lack of awareness about ill effects of tobacco. Five point Likert scale was used with options of ‘strongly agree’, ‘agree’, ‘unsure’, ‘disagree’ and ‘strongly disagree’, with scores being in the range of 18-90.

SLT usage and its cessation related practices were enquired using 22 items aiming at the age of subjects when first tried tobacco; frequency, duration, form, type of SLT usage; reasons to start, desire to quit and inability to quit tobacco; if they wish to and find it difficult to quit tobacco; have they ever stopped tobacco for at least a week; ever seek help of doctor or were counselled to quit tobacco.

Prior to the start of the main study, a pilot study was conducted among 53 patients. Results of the pilot study were used to calculate the sample size. The level of significance was fixed at 5% and the power of the study was fixed at 80%. The final sample size was estimated to be 158 for the present study.

The data was entered into the computer (MS Excel, MS Word) and Statistical Package for Social Sciences (SPSS), version 16.0 (SPSS Inc, Chicago IL) was employed for data analysis. Cronbach’s alpha and split half reliability tests were employed to assess the internal consistency of the knowledge, attitude and barrier domains. The differences among domains based on demographics as well as comparison of domain scores with regard to SLT cessation practices were evaluated using student’s t-test. Pearson’s correlation and chi-square test were used to assess correlations between various variables.

Reliability analysis of the pilot study revealed Cronbach’s alpha and split half reliability values of 0.83 and 0.70; 0.78 and 0.69; and, 0.87 and 0.78 for knowledge, attitude and barrier domains respectively. A total of 170 current SLT users (n) participated in the present study and were in the age range of 18 to 65 years with the mean age being 33.4 years. Majority of the study subjects were non-graduate (n=135, 79.41%), married (n=92, 54.12%), males (n=165, 97.06%), belonging to Hindu religion (n=138, 81.2%), having income of ≤Rs.10,000 (n=112, 65.88%) and were involved in occupations other than professional and semi-professionals (n=159, 93.53%) [Table/Fig-1].

Mean knowledge, attitude, worksite related practices and barrier scores were 9.96±3.86 (55.33%), 48.89±6.62 (81.48%), 2.70±1.85(33.75%) and 54.25±11.7(60.27%) respectively. Mean knowledge scores of subjects who were graduates and above (p<0.01), involved in semiprofessional or professional occupations (p<0.05) and with income ≥Rs.10,001 were significantly higher than their counterparts. Mean attitude scores were significantly higher among graduates and above and with income ≥Rs.10,001 (p<0.01). Mean worksite related practice scores were significantly better among respondents aged ≤30 years (p<0.05) [Table/Fig-1].

Correlation analysis of various domains with respect to demographics revealed significant association of knowledge with education (r=0.213, p=0.005), occupation (r=0.152, p=0.048) and income (r=0.168, p=0.029); attitude with education (r=0.211, p=0.006) and income (r=0.209, p=0.006); whereas, worksite related practices negatively correlated with age of the study subjects (r=-0.153, p=0.047) [Table/Fig-2]. Results also revealed that the knowledge was significantly associated with attitude (r=0.45, p=0.000) and worksite related practices (r=0.216, p=0.005); while the barriers in quitting smokeless tobacco negatively correlated with worksite related practices of the study subjects (r= -0.188, p=0.014) [Table/Fig-3].

SLT related practices revealed that the average age of the respondents when they first tried and regularly started using tobacco was 23.74±7.94 years and 25.18±8.39 years respectively. Majority of the study subjects chewed gutka (47.1%); daily chewed (95.3%); 1 to 5 times per day (62.4%); placed it in a particular site (57.6%); for an average of 13.30 (range: 1-60 minutes) minutes per use; spat out after chewing (94.1%); chewed at worksite (70%) and spent an average of Rs. 476.2(range: 10-3000) per month on SLT. Average time of first use of SLT for the day after waking up was 3 hour 54 minutes with 52.4% of subjects using SLT within the first hour of waking up. Peer and social pressure (24.7%), pleasure (20%) and stress (19.4%) were the major reasons for starting SLT among study subjects.

SLT cessation related practices showed that the majority of participants (n=153, 90%) wished to quit the habit, with the main reasons for the same being worry of tobacco related diseases (n=65, 38.2%) and fear of developing cancer (n=32, 18.8%). Most of them did not find it difficult to quit (n=97, 57.1%) and had stopped tobacco usage for at least a week (n=97, 57.1%). Majority of study subjects had not tried any form of medications or remedies to quit the habit (n=138, 81.2%); had not approached doctor seeking help to quit (n=152, 89.4%); and, were never counselled by doctor to quit (n=131, 77.1%). Most of the respondents reported that the major reasons for not able to quit was that they did not know how to quit (n=67, 39.4%) and their decision of not wanting to quit immediately (n=56, 32.9%). A total of 72.4% (n=123) were ready to quit immediately and 62.9% (n=107) did not feel the need of assistance in quitting tobacco.

[Table/Fig-4] shows correlation analysis of SLT cessation related practices with respect to demographics, revealing significant association of desire to quit with age (χ² =4.837, p=0.039) and occupation (χ² =9.083, p=0.015). Quit attempt of at least a week was significantly correlated with occupation of the respondents (χ² =4.259, p=0.05). Further notable was the significant association of religion with difficulty to quit (χ² =4.345, p=0.047), quit attempts (χ² =5.179, p=0.029) and attempts to seek help of doctor (χ² =4.668, p=0.026).

As shown in [Table/Fig-5], correlation analysis of SLT cessation related practices with respect to study domains revealed significant association of desire to quit with attitude of the study subjects (r= -0.167, p=0.030); difficulty to quit with barriers in tobacco cessation (r= -0.298, p=0.000); quit attempts with attitude (r= -0.162, p=0.035) and barriers (r=0.182, p=0.018); whereas, work site practices were associated with seeking help of doctor (r= -0.150, p=0.05) and counselling to quit tobacco (r= -0.211, p=0.006).

[Table/Fig-6] shows percentage of study subjects reporting various barriers to quit SLT use with respect to duration of SLT usage. It can be observed that the barriers to quit SLT use among those who have been using tobacco from the past 1-5 years and 6-10 years were “I am not interested to quit tobacco usage” and “I am not aware of ill effects of tobacco”. For study subjects who have been using SLT from the past 11-15 years, the barriers reported were “I am not interested to quit tobacco usage”, “I am not aware of ill effects of tobacco”, “I fear losing friends if I quit tobacco”, “I can’t quit tobacco because of social pressure”, “I fear I won’t succeed in quitting tobacco”, “I get discouraged when I try to quit tobacco”. Similarly the barriers, differed depending upon the duration of habit.

In order to restrain SLT usage, it is crucial to establish baseline data pertaining to the factors involved in SLT use and its cessation along with their varied interactions. Earlier work explored one or fewer aspects of SLT usage and its cessation [Table/Fig-7] [24–29]. The present work was one of the first attempt aimed at comprehensive exploration of various factors associated with SLT use and its cessation.

It is well appreciated that lack of knowledge and awareness are important factors that lead to initiation and persistence of SLT usage [1,15]. Although previous studies enquired one or fewer knowledge based questions [16,24,30], there is definite paucity of literature pertaining to exhaustive evaluation of knowledge related to SLT and its cessation. The present study aimed at addressing this void and the mean knowledge score was found to be 55.3%. The mean knowledge score was low despite the various measures exercised by the policy makers such as bold graphic embodiment of danger on SLT packets, audio-visual multimedia messages, ban on selling tobacco products, etc. This questions the implementation of such policies and directs attention towards the urgent need to further reinforce the existing policies and bring in newer measures aimed at prevention of SLT usage and promotion of its cessation.

Subjects who were graduates and above, involved in semiprofessional or professional occupations and with income ≥Rs.10,001 had significantly better knowledge scores than their counterparts in the present study, which could be attributed to their higher level of education. Majmudar et al., found association of better knowledge with higher level of education but not with income of their study participants [16]. Tiwari et al., also reported higher level of education with better knowledge [31]. Khawaja et al., found association of knowledge with age of their study subjects [32], contrasting the results of present study and Majmudar et al., [16].

Attitude of SLT users is a determining factor in the development, implementation and realization of measures targeted towards the prevention of SLT use and promotion of its cessation. Attitude of the present study participants was favourable (81.48%). Study participants who were graduates and above and those with income ≥Rs.10001 had better attitude scores, which could be attributed to their higher level of education. Despite having favourable attitude towards tobacco cessation, study participants were continuing SLT usage, pointing the inability of favourable attitude alone in controlling SLT use. This focuses attention towards importance of other variables like socio-demographic factors, worksite practices, barriers etc., which might play role in SLT usage and its cessation.

Individuals might get influenced by the practices of others at worksite due to sharing of time and same environment [33,34]. Engaging in certain occupations might even promote usage of SLT among the workers due to various reasons such as extended working hours, late night shifts, social acceptance, peer pressure etc. Similarly, implementation of targeted measures such as banning SLT use in and around work premises, conducting health talks, setting up of tobacco cessation clinics etc., might be more fruitful at worksite [33]. Binnal et al., noted that work site practices played significant role in smoking and its cessation [35]. Hence, monitoring worksite related practices might be important to control SLT usage. Worksite related practices among the present study participants were poor (33.75%), confirming the reports of Binnal et al., [35]. It was also noted that younger aged respondents had significantly better worksite practice scores than their counterparts. This could be attributed to the recent increase in the awareness programs conducted by the policy makers and to the fact that longer the duration of SLT use higher is its addiction, which could be true among older individuals.

Murthy and Saddichha proposed that lack of knowledge about ill effects of tobacco, cultural influences, lack of promotion of tobacco cessation and own use of tobacco by health professionals might act as barriers in tobacco cessation [36]. Hence, there is need to identify and eliminate the factors which impede tobacco cessation. Higher the barrier scores greater is the difficulty in SLT cessation. The present study barrier scores were 60.27% and were not influenced by any of the demographic factors under study. There is need to implement measures in order to overcome these barriers such as SLT related awareness programs, cessation clinics, ban its usage in and around schools, colleges and public places, etc. Studies pertaining to barriers associated with SLT cessation are scarce, future studies are required to elucidate further on these findings.

Significant association of knowledge with attitude and worksite related behaviour in the present study strengthens the importance of measures designed to improve knowledge towards harmful effects of SLT and benefits of its cessation. Barriers in SLT cessation were inversely correlated with worksite practices among present study participants, indicating better worksite practices if the existing barriers would be eliminated. These findings confirm results of Binnal et al., who reported similar findings among current smokers [35].

Confirming the previous reports [18,37], majority of the present study members chewed SLT daily, 1 to 5 times per day, at worksite, placed tobacco in a particular site, for an average of 13.3 minutes per use, spat out after chewing. Mean age of the respondents when they first tried and regularly initiated tobacco usage in the present study was 23.8 years and 25.9 years respectively, which is consistent with the results of Joshi et al., Mishra et al., and Kumar et al., [18,30,37]. In contrast, Majmudar et al. and Global Adult Tobacco Survey (GATS) India reported 15 and 17.9 years respectively as age at daily initiation [16,17]. Majority of study participants used SLT within an hour of waking up, which is consistent with the previous findings [16,17]. This indicates degree of dependence of the study subjects on SLT and hence might complicate tobacco cessation. The main reasons for using SLT among present study participants were peer and social pressure followed by pleasure and stress, which confirm the earlier findings [30,33,37]. SLT usage expenses among the participants of the present study was Rs. 476.2 (range: 10-3000), while Mishra et al., reported an average expenditure of Rs. 66.7 [30]. Study participants of Mishra et al., were industrial workers, while the present study included participants from diverse socio-economic backgrounds [30]. Although majority of our study participants had income ≤Rs.10,000, their SLT related expenses were considerably high. The results of the present study indicate that SLT related expenses might constitute a significant economic burden on their family.

The present study aimed at identifying factors that played role in SLT cessation. Majority (90%) of our study subjects wished to quit SLT usage which is consistent with the reports of Majmudar et al., and Agaku et al., [16,38], however conflict the observations of GATS India, Raute et al., Panda et al., [17,24,39]. Most of them had stopped SLT usage for atleast a week and claimed that they did not find it difficult to quit, confirming the reports of Majmudar et al., and conflicting that of Stoebner-Delbarre and Aghi [16,40]. Identifying the reasons behind intention to quit and inability to quit might be important to formulate strategies that facilitate SLT cessation. The main reason for intention to quit SLT usage among present study participants was fear of tobacco related diseases followed by fear of developing cancer, confirming the reports of Joshi et al., [18]. Majority of the present study respondents claimed that they were not able to quit and the reasons were that they did not know how to quit, their desire not to quit immediately and withdrawal effects. These findings point towards need to increase awareness that SLT is addictive hence might be difficult to quit, and, about whom to approach if they wish to quit.

Influence of the socio-demographic factors on SLT cessation related practices were also assessed in the present study. Significant association of age with desire to quit; occupation with desire to quit and quit attempts; religion with difficulty to quit, quit attempts and attempts to seek help of doctor. Panda et al., reported significant association of intention to quit with age, employment and previous quit attempts [39]. Early interventions to help quitting SLT usage especially among high risk occupational groups might be significant in promoting tobacco cessation practices.

Further notable findings were, better attitude scores among subjects who desired to quit and had tried quitting SLT; better worksite practice scores among those who seek help of doctor and who were counselled to quit tobacco; and, higher barrier scores among subjects who found it difficult to quit and those without any quit attempts. These observations need to be considered by the policy makers while evolving and executing SLT cessation methods. Newer policies exercising multiple approach strategy are required for effective SLT cessation. As this is first attempt at exploring various aspects of SLT cessation comprehensively, further studies are required to elucidate more on these issues.

The results of the present study must be interpreted in view of its limitations. Participants of the present study were SLT users visiting a dental institution. Hence, the results of the study cannot be extrapolated to the general population. As the present study is a questionnaire based research, it is susceptible to acquiescence (yea-saying), deviation (faking bad) and social desirability (faking good) biases. Further studies with larger sample size are required to confirm the results.

The present study draws attention towards involvement of multiple factors along with their complex interactions in SLT usage and its cessation. Socio-demographics play a significant role in initiation, perpetuation and cessation of SLT. In a country like India with growing population and limited resources, it is essential to consider these multitude of factors and adopt a multifactorial SLT control approach. Implementation of various measures such as SLT-free laws against SLT usage in public places; ban on advertisement, promotion and sale of SLT products especially around schools, workplaces; forbid sponsorships by tobacco industry, etc are required. Policy makers should also consider promotion and description of types of danger associated with SLT on SLT products; promoting SLT cessation activities such as setting up of SLT cessation clinics, promotion of various benefits of SLT cessation, anti-SLT campaigns, whom to approach if one wants to quit SLT usage, monetary benefits upon quitting, etc., in order to combat SLT hazard.