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Year : 2019  |  Volume : 17  |  Issue : 2  |  Page : 119-124

”Tobacco” – The silent slayer for oral premalignant lesions/ conditions among beedi rolling workers of Durg City, Chhattisgarh, India: A cross-sectional study

Department of Public Health Dentistry, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh, India

Date of Submission08-Nov-2018
Date of Acceptance29-Apr-2019
Date of Web Publication20-Jun-2019

Correspondence Address:
Dr. Heena Sahni
House No. 32 Arya Nagar, Opposite Dena Bank, Mohan Nagar Branch, Near Agrasen Chowk, Durg - 491 001, Chhattisgarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_215_18

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Background: Tobacco use is a major public health challenge and established risk factor for oral premalignant lesions and conditions in India. Workplace hazards are known to compromise the oral health of beedi-rolling workers. There is a scarcity of data about tobacco habits among these workers of Durg-Bhilai. Aim: This study aimed to assess the prevalence of tobacco-related habits and its associated lesions/conditions among beedi rolling workers of Durg-Bhilai, Chhattisgarh. Material and Methods: A cross-sectional study was conducted for 1 month among 185 beedi rolling workers of Durg-Bhilai city. Data were collected using a 25-item, self-structured, close-ended questionnaire based on oral hygiene habits, tobacco usage habits, awareness regarding tobacco, and its ill effects. After taking detailed habitual history, workers were screened for oral premalignant lesions. Oral cavity was only clinically diagnosed using World Health Organization assessment form of oral premalignant lesions and conditions. Descriptive statistics using Chi-square test were applied using SPSS software version 16 (IBM, Chicago, IL, USA), and P < 0.05 was considered statistically significant. Results: The prevalence of tobacco use was found to be 82.2%, with 15 (8.1%), 101 (54.6%), and 19.5% of workers involved in smoked, smokeless, and dual use, respectively. A total of 152 (82.1%) participants had one or more oral lesions. Leukoplakia and oral submucous fibrosis were observed in 27.6% and 13.5% of participants, respectively. Gudaku was used by 7.8% of participants, but it was not associated with any kind of oral lesions. Conclusion: The present study revealed a high prevalence of oral premalignant lesions with rampant misuse of tobacco products by these workers. There is an urgent need to create awareness regarding the ill effects of tobacco and also to initiate cessation programs among these workers.

Keywords: Beedi-rolling workers, oral cancer, oral premalignant lesions, smokeless tobacco, smoking

How to cite this article:
Yunus G Y, Sahni H, Naveen N, Tiwari R, Vasant B, Suman S. ”Tobacco” – The silent slayer for oral premalignant lesions/ conditions among beedi rolling workers of Durg City, Chhattisgarh, India: A cross-sectional study. J Indian Assoc Public Health Dent 2019;17:119-24

How to cite this URL:
Yunus G Y, Sahni H, Naveen N, Tiwari R, Vasant B, Suman S. ”Tobacco” – The silent slayer for oral premalignant lesions/ conditions among beedi rolling workers of Durg City, Chhattisgarh, India: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2019 [cited 2024 Mar 3];17:119-24. Available from: https://journals.lww.com/aphd/pages/default.aspx/text.asp?2019/17/2/119/260873

  Introduction Top

With a turnover of around 800 million kg, India becomes the third largest tobacco producer in the world after China and Brazil. Among various drugs abused, the most prevailing and commonly abused drug in the world is “Tobacco.” Today, one of the greatest sins in this world is tobacco addiction.[1]

In India, there is approximately 10 million workers employed in the tobacco-manufacturing industries, and it is estimated that 60% of them are women and 12%–15% of them are children, mainly young girls. The whole family members are involved in various jobs associated with tobacco such as planting, weeding, picking tobacco leaves, tying leaves, removing leaves after drying, and rolling of beedis.[2]

Large-scale beedi-rolling industries involve a large number of labors for their intensive cottage industry. Among these, big giants of tobacco manufacturing are small beedi-rolling workers who are either home-based workers or are employed in large-scale beedi-manufacturing factories. These beedi-rolling workers are involved in beedi-making works from young age and carry out all the works related to beedi making such as soaking, drying, and cutting of tendu leaves and finally filling the tendu leaves with sun-dried, processed tobacco flakes and tying with a cotton thread.[2]

These beedis are not only cheap in cost but also show relatively less combustibility as compared to standard cigarette due to nonporous nature of the tendu leaves, thus requiring more deeper and more frequent puffs by the smoker to keep beedis lit, and are therefore harder on smokers' oral and respiratory tissues.[3]

Tendu leaves which are mostly used for wrapping process to make beedis are mostly collected from government-owned forests in Madhya Pradesh, Chhattisgarh, Bihar, Jharkhand, Andhra Pradesh, Odisha, Uttar Pradesh, Maharashtra, Gujarat, Tamil Nadu, and West Bengal. These tendu leaves due to their ease of cultivation and ease of availability pave way for both registered and unregistered beedi-rolling factories to flourish in these states and so in Chhattisgarh.[4],[5]

In the present scenario, everyone is living in a stressful life working environment coupled with tobacco use habit which is a contributing factor for noncommunicable diseases such as ischemic heart diseases, cancers, diabetes, and chronic respiratory diseases, which are the leading causes of death globally. It is well known that many of the oral diseases such as periodontal diseases and premalignant lesions/conditions are caused primarily due to tobacco habit.[6]

Tobacco is a major risk factor for oral cancer, recurrence, aggressive periodontal breakdown, and may also lead to several congenital defects such as cleft lip and palate in children whose mother smoked during pregnancy.[7]

Although the oral cavity is accessible through visual examination, still oral mucosal lesions are diagnosed behindhand, so early diagnosis and treatment are crucial for the efficacious management of patients with oral premalignant lesions and conditions. Universally, it is a phrase that it is untroublesome to drop out good habits as compared to bad habits; these bad ones can lead to addictions. Similarly, when it comes to tobacco dependence, it is an enslavement which can lead to hazardous diseases and even death.

In India, tobacco is consumed in various forms, like, Cigarettes, Beedi's, Chutta, Chillam, Hookah are popular whereas smokeless forms include Gutkha, Khaini, Mawa, Gudaku.[8] India is the only country in the world which has the highest usage of smoked and smokeless tobacco.[9] Studies also showed that smoking and chewing tobacco when used together increases risk for developing cancer in the oral cavity.[10]

As per the Global Adult Tobacco Survey 2009–2010 reports Tobacco usage in Chhattisgarh was 30.1%.[11] There are approximately 25000 workers (from both unregistered and registered centers) employed in Beedi rolling work in Chhattisgarh, which mostly belongs to Low socioeconomic status and low literacy rate.[12] So, these subjects are at high risk of developing tobacco related oral lesions and conditions.

In addition to this, being a part of Central India, there is a shortage of epidemiological data related to tobacco consumption habits and its associated oral mucosal lesions/conditions among these workers. Hence, this study was conducted to assess the prevalence of Tobacco related Habits and prevalence of tobacco associated oral mucosal lesions/conditions among Beedi rolling workers of Durg-Bhilai Chhattisgarh.

  Material And Methods Top

This study was designed as a cross sectional study which was conducted from a period from September 1 to September 31, 2017. There are only two registered and licensed factories in Durg-Bhilai and both the factories were considered in the study. Prior to the commencement of the study an ethical approval was obtained from Institutional Ethical Review Board (RCDSR/IEC/MDS/2017/S1) in addition to permission from respective Beedi factories for the conducting of the study.

A convenient sampling method was used to survey and examine rolling workers to find out the prevalence of tobacco use and associated oral mucosal lesions in two rolling factories as only two rolling factories were found to be registered and it was near impossible to find out unregistered and un-licensed factories working in the area. It was estimated that a minimal sample size of 185 would be required for the study.

The study participants were approached by taking permissions from the concerned authority (factory owner) of the factories. The objectives of the study were explained and after they gave the permission the study subjects were examined. Before conducting the interview process and oral examination an informed consent was obtained after explaining the purpose and procedure of the study in the language they understand i.e., Chhattisgarhi or Hindi Language.

The inclusion criteria included subjects working in beedi factories and were present at the time of study. Exclusion criteria were the subjects who were not willing to give habit details and further examination.

A self-designed pretested, close ended questionnaire was used to collect information regarding demographic details of the participants, oral hygiene practice, years of work experience in beedi making and tobacco use habit among beedi rolling workers. This questionnaire was tested for its face validity by research guide and modifications were made accordingly. Cronbach's alpha was estimated to be 0.81; this indicates the “Good” reliability of the designed questionnaire For each worker detailed oral examination was preceded by a face to face interview in the language they understand so to gather relevant information in most efficient way.

Before the start of the study, the investigator was trained and calibrated under the supervision of faculty members in the Department of Oral Medicine Diagnosis and Radiology, Rungta College of Dental Sciences and Research, Bhilai, Chhattisgarh. Training session lasted for 7 days which included discussion of all parameters with the experts from the department of Oral Medicine and Radiology (OMR), demonstration of examination by faculty members.

A minimum of 20 subjects were examined in the age group of 18 years or above, to understand and get trained with identification and examination of tobacco associated oral mucosal lesions/conditions under the supervision of department faculty members.

The results of two examinations were carried out with the gap of 10 days and so the kappa value for intra examiner reliability was found to be 0.79. On average 10–15 patients were examined per day. The instruments used for clinical examination was plain mouth mirror and probe. Intraoral examination was performed to record findings like type, and location of oral mucosal lesions using World Health Organization assessment form of oral premalignant lesions and conditions.[13]

All the instruments were cleaned and autoclaved before carried to the study site. The used instruments were collected in a separate container and when required, necessary chemical disinfection was undertaken using 10% Korsolex solution followed by washing in distilled water.

Statistical analysis

The obtained data was entered in Microsoft Excel Spreadsheet analyzed using SPSS software versions 16 for windows (IBM, Chicago, IL, USA). Descriptive statistics were carried out to obtain frequency, percentage and mean and Chi-square test was used to determine the association between working experience in beedi rolling work and occurrence of oral premalignant lesions and conditions. P < 0.05 was considered as statistically significant.

  Results Top

Among 185 enrolled beedi rolling workers, 74 (40%) were males and 111 (60%) were females with mean age of 44.82 ± 13.54 years. Out of which, 17.8% were non-Tobacco user while 82.2% were having habit of Tobacco consumption. Subjects with smoked, smokeless and dual use tobacco habit were 8.1%, 54.6%, and 19.5% respectively [Table 1].
Table 1: Distribution of participants according to tobacco use habit

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Among smokeless form, Gutka (16.4%) was most frequently used tobacco product. Other forms of tobacco consumed are as follows: Gudaku (7.8%) = Beedi (7.8%) = Khaini (7.8%) > Betel quid with tobacco (3.2%) > Cigarette (2.6) >Raw Arecanut with tobacco (1.3%) [Table 2].
Table 2: Product use among smoked and smokeless tobacco users

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Majority of tobacco consumer's i.e.,75.6% reported that they are involved in tobacco use to acquire pleasant feeling, while 19.7% reported for using it as stress reduction tool after stressful work whole day. Peer pressure and curiosity also accounted tobacco use habit in 2.6% and 1.9% respectively [Table 3].
Table 3: Frequency and percentage of responses to questionnaire items

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Among majority tobacco users, majority i.e., 95.3% of them ever noticed about any kind of discoloration or stained on their teeth due to habit. Even when asked about any kind of burning sensation or pain they noticed while using tobacco or as after effect, majority i.e., 87.5% denied of experiencing it. Also 90.7% reported of not realizing any kind of reduced mouth opening [Table 3].

When researchers tried to assess the awareness regarding ill effects of the tobacco use majority i.e., 83.8% of beedi workers affirmed that “yes” they are aware of the ill effects for which the main source of awareness was television/radio in case of 64.3% workers while 29.1% reported that source of information in form of advice by family/friend. Whereas newspaper/magazine and books/pamphlets to be the minor source accounting for awareness among only 4.9% and 1.6% workers only [Table 3].

Quitting the tobacco use habit was never an agenda for 62.5% workers while 37.5% reported of attempting to quit tobacco but failed. Main motive to quit tobacco use habit was gaining health for 90.7% workers. While second best motive was elimination of bad odor from mouth for 6.5% workers [Table 3].

Prevalence of various tobacco associated lesions and conditions in study population

Among oral mucosal lesions, Leukoplakia (LP) was the most prevalent (27.6%) followed by tobacco pouch keratosis (7%), smoker's palate (5.9%), erythroplakia (2.2%) and quid induced keratosis (1.6%). And most frequently oral mucosal condition countered was oral submucous fibrosis (13.5%) [Table 4].
Table 4: Prevalence of oral mucosal lesions

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Frequency of oral mucosal lesions and conditions at different locations in the oral cavity

Buccal mucosa (44.5%) was the most commonly involved intra oral site for tobacco related oral premalignant lesions and conditions. Other frequently involved locations are arranged as follows: Buccal mucosa > labial vestibule > buccal sulcus > hard/soft palate > alveolar ridge [Table 5].
Table 5: Location of oral mucosal lesions countered

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The association between working experience of subjects in beedi rolling and occurrence of oral premalignant lesions and conditions was found to be highly statistically significant (P = 0.001) [Table 6].
Table 6: Distribution of oral mucosal lesions according to work experience

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  Discussion Top

Tobacco consumption habit has many phases over the period of time and those changes in risk habits and urbanization leads to alterations in the patterns of oral cancer, like the age of onset, duration and sub site predilection.[14] Beedi manufacturers indirectly promote smokeless form of tobacco because in certain conditions where smoking is not allowed people got addicted to other chewing tobacco product along with smoked form.[15]

The overall prevalence of tobacco consumption in present study was 82.2% which was higher than that reported by Mishra et al. i.e., 24.78% in Rewa (M.P) and 51.4% reported by Pratik and Desai in Jaipur Rajasthan.[9],[15] As seen from the present study findings, 98.6% males were tobacco users and 71.2% females were having this habit, even after the number of female participants were more, then also tobacco consumption shows males predominance, which was similar to the findings of a study conducted in Dharwad by Patil et al. and Gupta et al.[10],[16]

There is an increase in consumption of smokeless form of tobacco (Gutka, Khaini, and Gudaku) especially in Central India. In the present study, Smokeless form (54.6%) of tobacco was more prevalent than smoked form (8.1%) which is similar to the findings reported by Nair et al. (67%) but in contrast to the study by Vikneshan et al. where 50.6% were smokers.[8],[17] Also in our study 19.5% of subjects consume dual form (smoking and chewing) of tobacco which is in accordance with but in contrast to Joshi M et al.[13],[17]

Gutka (16.4%), Khaini (7.8%) and Gudaku (7.8%) was the most popular smokeless tobacco product which is comparatively higher than smoking habit. Which may be attributed the belief rural population that Gudaku is beneficial product for cleaning teeth and maintaining oral hygiene. Also women involved in beedi rolling believe that Gudaku has many medicinal properties in treating toothache, headache, for cleaning tooth and they also feel ease in defecation.

The prevalence of LP in our study was 27.6% which is in contrary to study reported by Vanishree et al.(2.6%), Joshi and Tailor (0.3%) and Reddy et al. (8%), but were similar to results reported by Naveen-Kumar et al. study (61.2%).[18],[19],[20],[21] In brief, our results show that the habit of tobacco consumption is a very strong causative factor for cancer of oral cavity and its related lesions/conditions which is a constant finding of previous studies.

Beedi rolling not only being stressful because of repetitive action work, but also impose tremendous stress due to pressure of achieving daily limit of beedi rolling imposed by the supervisors. This stressful environment makes the worker less concerned about their health which might be the most important factor for beedi workers using tobacco of not noticing discoloration of teeth, and burning sensation or pain occurring un-noticed. This not only create a need to educate them about consequences of neglecting health issues but also creates a need to reduce the worker pressure and create environment friendly.[22],[23]

Limitations and recommendations

Our study includes participants from only two rolling factories which were registered in the area and there was no method to track down unregistered and un-licensed factories working in the area so the results of the study cannot be generalized to the factories of the other states or place. Also, all the findings were based on clinical examination but to confirm the diagnosis, histopathological examination serves as an accurate tool. This study only provides glimpse of the problem of tobacco usage habit among rolling workers and associated oral mucosal lesions/conditions but large scale studies which includes workers from unregistered and un-licensed factories are needed to prove the fact.

  Conclusion Top

The overall prevalence of tobacco consumption in present study was 82.2%. LP was detected in 27.6% cases. A significant number of people (82.2%) are being initiated into the habit because of easy availability and access to the tobacco products in these manufacturing sites. Periodic Oral cancer screening camps are organized to monitor this part of population and efforts should be made for effective implementation of the tobacco cessation counseling programs through which will likely to have impact not only on the prevention of tobacco consumption habit; but also on awareness regarding ill effects of tobacco on large scale.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]

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