Multiple Tobacco Products Use: Exploring possibility of an independent indicator for nicotine dependence

INTRODUCTION: Tobacco products are source of nicotine to our body. Time to first Smoke (TTFS) and cigarettes smoked per day (CPD) are two important and frequently used indicators of nicotine dependence. These together constitute heaviness of smoking index (HSI). Product specific nature of nicotine dependence, low consumption of cigarettes and use of multiple forms of tobacco products in India made these indicators less reliable. Since simultaneous use of multiple tobacco products may indicate craving for nicotine from whatever source, possibility of ‘multiple use’ as a reliable and independent indicator of nicotine dependence is explored in this study.

METHODS: The current daily users of manufactured cigarette who smoked only cigarette (nil simultaneous use of other tobacco products) were termed as exclusive users and rest using any other tobacco products (smoking/smokeless) simultaneously was defined as multiple users. These groups were compared for predictability of dependence outcome indicators (quit intention and quit attempt). GATS weight was not used for this non random sub-sample analysis.

RESULTS: Higher proportion (77.4%) of multiple users had shown little quit intention than cigarette-only (74%) users (p=0.036).  Similarly, significantly (p=0.003) higher proportion (71.7%) of multiple users had had not made any quit attempt than their cigarette-only (67.0%) use counterparts. Further ‘multiple use’ had higher concordance with high dependence categories like time to first smoke < 30 minutes and heaviness of smoking index score ≥ 4.  

CONCLUSION: No past quit attempt and little quit intention in future are definite features of high nicotine dependence. ‘Multiple usage’ of tobacco products is significantly associated with these dependence outcome indicators. In these context possibility of giving weight for multiple use  while assessing nicotine dependence is warranted. Further studies with factor analysis, correlation with biological markers and comparison with other valid dependence measure should be given research priorities.