Snuff Usage and Knowledge Regarding Its Effects Among Pakistani Male Students of Public Medical University, Peshawar

: In Pakistan, snuff, locally known as Naswar, was introduced decades ago, and is usually processed into a loose moist form


Introduction
Snuff, also known as Naswar in Pakistan, was first introduced about 400 years ago and is commonest smokeless tobacco (SLT) product.It is always manufactured into a loose moist form, and its consumption is extensive throughout the country.Naswar is made from Nicotiana Rustica tobacco, and the fermented ground powder is blended with an aqueous sodium bicarbonate solution.The resulting product is moist, has a strong aroma, is highly addictive, and is popular, -in particular between males especially youth.It has a pH of 8-11, an amount of moisture of 6-60%, and a nicotine content of 8 to 102 mg/g dry mass [1].The most common types of oral mucosal soft-tissue lesions caused by smokeless tobacco and tobacco products are oral squamous cell carcinoma (SCC) and Verruca's carcinoma, as well as oral chronic inflammatory disorders (OPMDs) (leukoplakia, erythroplakia and erythro-leukoplakia).The International Agency for Research on Cancer (IARC) evaluated the cancer -causing potential dangers of smokeless tobacco and affirmed that it is cancer-causing to humans, with the main targeted organ being just the oral cavity in which the ingredients are applied locally [2].In Pakistan, preparation of smokeless tobacco (Naswar), is inexpensive and poorly regulated.Oral cancer which is ranked the sixth amongst all cancer types in Pakistan is strongly associated with this habit.a broad range of psychological, social, environmental, and genetic factors are linked with the use of tobacco and its by-products [3,4].
Snuff is the most commonly used SLT product in Asian countries and has a number of local variations.Moist snuff is locally referred to as chemma and is the most used product in Asian countries.Naswar is a moist tobacco product that is used in Pakistan.Dry snuff is referred to as Neffa in Asian countries.Taaba is a dry snuff that can be applied to the gums or the soft palate although it is most generally aspirated through the nasal passages.This type of Snuff is local to Sri Lanka, Afghanistan, India, and Iran.SLT products' ingredient profiles and accompanying toxicity levels differ across Asian countries.Higher pH values have been linked to more severe abnormalities, lending to the idea that such a higher component pH is linked to increased toxicity.A literature review of factors associated with the development of oral cancer in Pakistan discovered a connection between the use of Naswar and the risk of developing oral cancer [5].Smokeless tobacco is used orally or nasally and therefore is consumed without combusting the product.Sublingual SLT products are absorbed (dipped) or chewed after being located in the tongue, buccal mucosa, or lip.Pollutants in smokeless tobacco make a contribution to the development of oral cancers and the risk of other neck and head cancers.Naswar; the product constituents are tobacco and sodium bicarbonate, and the geographic location of use is Pakistan.The component is rolled into something like a ball that weighs about 10g and is known as a Saffa.The saffa is managed to hold between the gum and the lip or cheek, or on the floor of the mouth under the tongue.It gradually sucks for 10 to 15 minutes [6].
Cultural norms, risk awareness as well as social influences, and are among the many considerations.These components could be closely linked to stress reduction, peer pressure, life problems, social acceptance, a family background of tobacco use, parents with a lower level of education and a desire to accomplish a high personality profile.Children who have parents or friends and family who smoke seem to be more likely to start smoking themselves, according to research.Experimenting with tobacco use, on the contrary, may be a direction to rebel against adult authority, bond with peers, or develop personal identity [6].Tobacco continues to be a serious threat to worldwide health, killed approximately 6 million individuals annually and causing tens of billions of dollars in damage to the economy in the form of increased health-care expenses and lost productivity.Tobacco use represents the most frequently reported substance abuse among students.There is currently no official tobacco control policy in Pakistan that specifically targets adolescents [7].
One of the most significant barriers to efficient intervention to address public healthcare needs is a lack of understanding of the nature of the problem.This is most evident at the point between determining the effectiveness of interventions and implementing them in policies and practices.While global estimates of the scale of the issue exist, actual measurement of the significant degree and influence at the local and national level is most often suffering from a lack [8].In developing programs against tobacco habits of adolescents', there is need to aim the impact of friends and parents because they have great significance [9].This study aimed to get baseline information about the Naswar use among Pakistani university students, including their knowledge about Naswar associated health risks and thoughts and opinions towards their role in controlling the use Naswar.
Majority of male snuff dippers patients when they are attending to dental hospitals and are asked about the age of initiating the snuff usage, they answered that secondary schools and university, so young males in universities must be the targeted group to investigate and eradicate the problem.To determine the magnitude of the problem and the driving factors we have to measure the frequency of the snuff usage and to assess the knowledge regarding its usage because the degree of awareness and recognition of harmfulness of a condition on health can reduce the rate of usage.After investigating the problem, we will be able to design suitable public health program for smokeless tobacco prevention among youth.This study was done to study snuff usage and knowledge regarding its effects among Pakistanis male students in Khyber Medical University, Peshawar 2019.

Methodology
It was a descriptive cross sectional institutional based study done at Khyber Medical University, Peshawar.Khyber Medical University, Peshawar has 21 colleges arranged in 4 complexes.Khyber Medical University, Peshawar has 5251 male students for 21 colleges.

Study Population
Pakistani male students from Khyber Medical University, Peshawar during academic year 2019 -2020.

Inclusion Criteria
Pakistani male students present at the time of the study.

Exclusion Criteria
1) Students who refuse to participate.2) Absent students during the study period.Public Medical University, Peshawar

Sample Size
Since we had the full frame of all male students at Khyber Medical University, Peshawar divided by their colleges.Then the formula for calculating the sample size for a finitepopulation (Students Frame) as follows: = * * e: Desired margin of error = 5%; p: The estimated proportion of snuff usage in the population.= 0.5; z: Critical value of standard deviation curve at zero level.=1.96; N: The population size (frame size).= 5251; Based on the formula above with a population size (N = 5251), confidence level 95% (z = 1.96), margin of error (e = 5%), and (p = 0.5) the initial sample size is 358 and by adding 10% as margin of non-response rate the final sample size will approximately be 400.

Sampling Technique
Random sampling technique was to select a sample of 400 students from all the students at Khyber Medical University, Peshawar (5251).We followed the Stratified Multi-Stage Technique.

Data Collection
A self-administered questionnaire was used for data collection and was filled with participants in their rest time without any interruption to their lectures.The questionnaire was modified from previous similar studies [10].Students coming to university regularly 3-5 days per week were selected.The researcher took 20 students per day, so within a month the data was collected (400 Students).The researcher trained 4 colleagues, who assisted in the data collection process.

Data Management and Analysis
The collected data was coded, entered in master sheet, and analyzed by Statistical Package for Social Sciences SPSS (IBM SPSS Inc., Chicago, version no.25) software.All statistical analysis was set at 95% confidence level and the level of significance (alpha) 0.05.Descriptive statistics was presented in the form of tables of frequency, charts, and graphs.Likert Measure, Correlation, and Chi-square test was used.

Ethical Consideration
Approval of the study was obtained from: 1) The Pakistan Medical Specialization Board and Educational developmental center (EDC) ethical committee.
2) The deanship of students affair /Khyber Medical University, Peshawar.3) Research purposes and objectives were explained to the participants in clear simple words.Participant has right to voluntary written informed consent, withdraw at any time and to no harm (privacy and confidentiality by using coded questionnaire).

Results
This study conducted to estimate the prevalence of snuff usage among Pakistanis male students at the Khyber Medical University, to determine the predisposing (initiative/stimulating) factors of snuff usage among them and to assess the knowledge regarding to the side effects of snuff dipping on the oral health among Pakistanis male students at Khyber Medical University, Peshawar.According to Likert measure, the overall mean was 1.63, which means the majority was strongly agree, so it indicates a particularly high level of knowledge.The mean level of knowledge was very high knowledge (strongly agree).

Prevalence of Snuff Usage
Which description fits you best in snuff dipping?

Knowledge of Snuff Dipping Users
When knowledge was assessed among students at KMU by Chi-square = 19.023,there was high significant P-value = 0.000 (Figure 1).As mentioned in Figure 2, no significant influence of friends was observed as risk factor for snuff dipping among students at Khyber Medical University with Chi-square = 0.221, and P value = 0.638.No significant comparison was observed between snuff dippers and non-snuff dippers in the lack of knowing the health risks as risk factor for snuff dipping among students (Figure 3) with P value = 0.730.When comparison between snuff dippers and non-snuff dippers in the thinking that snuff can relieve anxiety as risk factor for snuff dipping among students with P value = 0.014 (Figure 4).

Discussion
Assessment of the knowledge regarding the side effects of snuff dipping on oral health.According to Likert measure, the overall mean was 1.63, which means the majority strongly agree, so it indicates very high level of knowledge as indicated in table 2 and 3. Predisposing (initiative) factors of snuff usage as in table 4, the greatest predisposing factor was friends effect (81.5%), followed by thinking that it relieves anxiety (79.8%) whereas the least predisposing factor was the advertisement effect (23.8%), which is closed to the findings revealed by: Imam et al. " Use of smokeless tobacco among groups of Pakistani medical students -a cross sectional study [11], and Zohaib Khan "A Gaping Gap (Smokeless Tobacco Control in Pakistan)."[7].
Prevalence of snuff usage shown in table 5 and 6 concludes that the overall prevalence of snuff usage was 174 (43.5%) which was high, there were studies revealed similar results conducted by: A. M. Idris et al. about "Naswar Use and Cigarette Smoking in the Sudan" [1], Ahmmed, "The Epidemic of Tobacco Use among the Students of University of Bahri-Khartoum-Sudan-2014." [6], and Amrita Sarkar et al. "A population-based study on tobacco consumption in urban slums" [12].There was a study that found that the prevalence of tobacco use is higher than this present study which was conducted by C. Althaf Hussain et al about: "Tobacco prevalence and usage pattern among Bengaluru urban slum dwellers" [13].
While this study found that the prevalence of snuff usage was high, in contrast, there were studies found the prevalence of it was low, which were: study conducted by Jones, Dina M. et al. about "Prevalence and Factors Associated with Smokeless Tobacco" [14], study carried out by Ikenna Onoh, et al about "the Prevalence, patterns and correlates of smokeless tobacco use in Nigerian adults" [10] and the study conducted by Sreeramareddy et al. about: "Smoking and smokeless tobacco use in nine South and Southeast Asian countries" [4].
The least group in the initiation of snuff usage was less than 12 year old (5.2%) whereas the majority initiated to use snuff at age more than 18 year old (58.6%) so this indicates that most of youth tend to develop this habit when they were leaving the high school level and move to the university level, and this finding is similar to the study conducted by: Mohammad Hanif Memon et al about: "Knowledge Assessment about Hazards of Smokeless Tobacco Use in Patients coming to a DHQ Hospital" [15].The lowest percentage of the frequency is (2.3%) for the group who take snuff (1-5) days during the past 30 days whereas the highest percentage of the frequency is (48.3%) for the group who take snuff all the 30 days which also indicates that the snuff usage is highly addictive, table 7.

Conclusion
The overall knowledge level was very high according to Likert measure.There was significant relationship between knowledge level and snuff usage, the knowledge level within non-snuff dippers was 92% which was very high, whereas the knowledge level among snuff dippers was (76.4%) which was high, so there is need to raise the knowledge level as a step in the way to prevent snuff usage.The prevalence of snuff usage among Pakistani male students in the Khyber Medical University, Peshawar was 174 (43.5%) n = 400, which was high.The greatest predisposing factor was friend's effect (81.5%) whereas the least predisposing factor was the advertisement effect (23.8%).The range of the duration of using snuff from 1-11 years.The least group in the beginning of snuff usage was less than 12-year-old (5.2%) whereas the majority began to use snuff at age more than 18-year-old (58.6%) so this indicates that most of youth tend to develop this habit when they are leaving the high schools level and move to the university level.There is an urgent need for intervention by providing tobacco prevention program for raising awareness regarding to the health hazards of tobacco use and counselling to help and encourage users for cessation and to prevent tobacco initiation.

Figure 1 .
Figure 1.Comparison between snuff dippers and non-snuff dippers in knowledge assessment level.

Figure 2 .
Figure 2. Comparison between snuff dippers and non-snuff dippers in the influence of friends as risk factor for snuff dipping.

Figure 3 .
Figure 3.Comparison between snuff dippers and non-snuff dippers in the lack of knowing the health risks as risk factor for snuff dipping among students.

Figure 4 .
Figure 4. Comparison between snuff dippers and non-snuff dippers in the thinking that snuff can relieve anxiety as risk factor for snuff dipping among students.

Table 1 .
Distribution of sample size by age in each study level/Khyber Medical University, n=400.

Table 2 .
Assessment of knowledge regarding the side effects of snuff dipping according to Likert measures.n=400.

Table 3 .
Descriptive statistics for Likert measure for the Assessment of Knowledge regarding to the side effects of snuff dipping (n=400).

Table 4 .
Predisposing (initiative) Factors of Snuff usage among male students.

Table 5 .
Description of snuff dipping status among male students in Khyber Medical University, Peshawar.

Table 6 .
Classification of sample size into 2 groups (snuff dippers and non-snuff dippers) among male students n=400.