Journal of Indian Association of Public Health Dentistry

: 2020  |  Volume : 18  |  Issue : 1  |  Page : 35--40

Association of occupational stress and nicotine dependence with oral health status among public transit workers in Bangalore: A cross sectional study

Niharika Benjamin, Umashankar Gangadhariah Kadaluru, Vishakha Rani 
 Department of Public Health Dentistry, M. R. Ambedkar Dental College and Hospital, Bengaluru, Karnataka, India

Correspondence Address:
Dr. Umashankar Gangadhariah Kadaluru
Department of Public Health Dentistry, M. R. Ambedkar Dental College and Hospital, 1/36, Cooke Town, Bengaluru - 560 005, Karnataka


Background: Public transportation is an example of high-strain occupation and its workers are dealing with immense stress. Occupational stress has been seen to promote tobacco use and this habit is widely present among the transit workers. Both occupational stress and tobacco habit have their adverse effect on general as well as oral health. Aim: This study aims to assess the association of occupational stress and nicotine dependence with oral health status among public transit workers in Bangalore city. Materials and Methods: This cross-sectional survey was conducted among 450 public transit workers in Bangalore. The extent of occupational stress was assessed using 20-item questionnaire. Nicotine dependence was measured using the Modified Fagerstrom Tolerance scale for smoking and smokeless tobacco. Recording of oral mucosal lesion and community periodontal index were done for the assessment of oral health status. Data were analyzed using statistical Package for Social Sciences software (SPSS version 24) using Chi-square test and binary logistic regression (P < 0.05). Results: The results of bivariate and multivariate analysis elicited significant association of periodontal health with gender (P = 0.011), level of nicotine dependence for smoking (P = 0.008) and smokeless tobacco (P = 0.002) and occupational stress (P = 0.035). The oral mucosal lesion was seen to be associated only with level of nicotine dependence for smoking (P = 0.008) and smokeless tobacco (P < 0.001). Conclusion: In the present study, poor oral health status was associated with occupational stress and nicotine dependence. As these factors have individual as well as synergistic effect on oral health, a multirisk approach and workplace interventions to reduce job stress and strategies to promote oral health are the need for status quo.

How to cite this article:
Benjamin N, Kadaluru UG, Rani V. Association of occupational stress and nicotine dependence with oral health status among public transit workers in Bangalore: A cross sectional study.J Indian Assoc Public Health Dent 2020;18:35-40

How to cite this URL:
Benjamin N, Kadaluru UG, Rani V. Association of occupational stress and nicotine dependence with oral health status among public transit workers in Bangalore: A cross sectional study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2020 Nov 26 ];18:35-40
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Stress is a fact of life and can affect individuals in variety of physical and psychological ways. Various factors can lead to stress in humans and one such factor is occupation. The work overload, organizational climate, long working hours, salary, and the risk of being fired conform some of the aspects that generate stress to workers.[1] It is difficult to consider any occupation that does not generate stress; one of them is to be the driver or the workers of a public transportation vehicle of passengers.[2],[3] Especially in developing countries where in most cases, the current state of its transportation system is not based on the needs of the population.[4] India's passenger transport for small and medium distances is bus oriented. Transit workers have huge responsibility to overcome traffic congestion and to get passengers safely and comfortably in scheduled time to the desired destination. The challenge is even more in a metropolitan city with its immensely crowded population.[5]

Occupational stress has an aversive effect on individuals and organizations. It is well known that stress cause's oral health diseases like periodontitis.[6],[7],[8],[9],[10],[11],[12],[13],[14],[15] Number of studies have also shown an association between the occurrence of acute necrotizing ulcerative gingivitis and negative life events and stress arising from life situation.[16],[17],[18],[19],[20]

Stress in transit workers leads to various form of substance abuse, among which tobacco is most commonly used.[5] Different studies have discussed a correlation between smoking and occupational stress.[21],[22],[23] It is widely believe that tobacco use among bus drivers and other staffs is very high, the staffs working in transportation are mostly school dropouts and they gets involve in these deleterious habits early in their life. Tobacco use is the second cause of mortality worldwide and the first cause of preventable morbidity and mortality.[24],[25] The most significant effects of tobacco on the oral cavity are: oral cancers and potentially malignant lesions, increased severity and extent of periodontal disease, as well as poor wound healing.[26]

The road public transportation and the workers under it, plays a vital role in the development of our country so their health should be a major country's concern. Till date, no research has been done to know the relationship between occupational stress, nicotine dependence, and its effect on oral health status among public transit workers. Hence, the aim of this study was to assess the association between occupational stress, nicotine dependence, and oral health status among public transit workers in Bangalore city.

 Materials and Methods

This cross-sectional study was conducted among transit workers (including bus drivers, conductors, mechanics, administrative section, and others) working at Karnataka State Road Transport Corporation (KSRTC) and Bangalore Metropolitan Transport Corporation (BMTC) bus depots. The data were collected during a work-place tobacco intervention programme from April 2018 to May 2018.

The ethical approval was granted by Institutional Ethical Review Committee for Protection of Research Subjects (Ref: MRADCandH/ECIRB/2017-2018), and organizational consent was taken from the managers of BMTC and KSRTC bus depots. Individual informed consent was obtained before the data collection. Transit workers under KSRTC and BMTC with minimum 1 year experience were included in the study. The workers with systemic illness or disability and those who were on leave during the period of this study were excluded.

According to BMTC and KSRTC official reports there are total 70 thousand workers working under them. Open-epi software (Andrew G. Dean, Kevin M. Sullivan, Atlanta, GA, USA) was used for sample size calculation, considering an expected prevalence of 50%, and using a confidence level of 95%, the sample size was calculated as 450.

The participants were selected randomly from the different routes of bus stand.

Data collection

Data were collected through a face to face interview using a structured questionnaire. This standardized questionnaire has the reliability coefficient ascertained by Split half (odd-even) method and Cronbach's alpha-coefficient for the scale as a whole to be 0.937 and 0.90, respectively.

The questionnaire consisted of four sections. (i) Section I consisted of demographic characteristic, which included questions concerning age, gender, education, marital status and nature of work. Age was categorized into four groups (20–30 years, 30–40 years, 40–50 years, and 50–60 years), the groups are selected to facilitate the inclusion of all the staffs working in the transportation, the level of education was categorized as primary school, secondary school, PUC, diploma, ITI, graduation or any other. Nature of work was differentiated into six categories: driver, conductor, both, mechanic, administrative and others. (ii) Section II consisted of occupational stress questions, there were total 20 questions with options following a 5-point Likert scale (strongly agree = 5, agree = 4, disagree = 3, strongly disagree = 2 and unsure = 1).[27] (iii) Section III consisted of Modified Fagerstrom scale for smoking and smokeless tobacco, each scale consisted of 6 questions and each question carried some point/score based on the answer.[28] The subjects were asked to answer the questions as per their experience of tobacco consumption. The overall score was the summation of scores of all questions. Minimum score was 0 and the maximum score was 10.[29] The interpretation of scoring was: 7–10: person is highly dependent; 4–6: person has low to moderate dependence; below 4: person has low addiction; and (iv) section IV included recording of CPI index and oral mucosal lesion using WHO pro forma 1997 with the help of clinical examination.

Statistical analysis

Analyses were performed using a personal computer with Statistical Package for Social Sciences [SPSS version 24 (IBM corp. Armonk, NY, USA)]. A significant relationship was assumed to exist if the P value was found to be <0.05. Chi-square test was used to check the association of periodontal disease and oral mucosal lesion according to sociodemographic details, occupational stress and nicotine dependence. Binomial regression analyses were performed to assess the effect of various independent variables on the dependent variable (periodontal disease and oral mucosal lesion).


The mean age was 38.48 ranging from 20 to 60 years, the age distribution was found to be discrete. Among 450 participants, 390 (86.7%) were males and 60 (13.3%) were females. Maximum participants, i.e., 126 (28%) had completed PUC and only 22 (4.9%) of them had completed diploma course. Among 450 study participants, 393 (87.3) were married and 57 (12.7%) were unmarried. According to nature of their work maximum number of participants who numbered 142 (31.6%) were mechanics, followed by drivers and driver/conductor who were 120 (26.7%) and 78 (17.3) in numbers, respectively [Table 1].{Table 1}

According to presence or absence of tobacco habit, 192 (42.7%) were smokers, 116 (25.8%) had a habit of chewing tobacco and 31 (6.8%) participants had a habit of both. Among 450 participants, 111 (24.7%) had reported absence of these habits. 265 (58.9%) study participants reported high work place stress and 185 (41.1%) participants, reported low occupational stress [Table 2].{Table 2}

There was no statistically significant association between periodontal disease and any of the age groups selected (P = 0.106), marital status (P = 0.298) and education (P = 0.057); however, statistically significant association was seen between periodontal disease and the gender (P < 0.001), nature of work (P < 0.001), occupational stress (P < 0.001) and modified Fagerstrom scale for smoking (P = 0.001) and smokeless tobacco (P = 0.001). Similarly, there was no statistically significant association between oral mucosal lesion and age (P = 0.244), marital status (P = 0.228), education (P = 0.074), and occupational stress (P = 0.085); however, a statistically significant association between oral mucosal lesion and gender (P = 0.034), nature of work (P = 0.042) and nicotine addiction for smoking (P < 0.001) and smokeless tobacco (P < 0.001) [Table 3], [Table 4], [Table 5].{Table 3}{Table 4}{Table 5}

The result of binary logistic regression analysis for the factor influencing periodontal health showed that among the examined factors, only gender (P = 0.011), nicotine dependence for smoking (P = 0.008) and smokeless tobacco (P = 0.002) and occupational stress (P = 0.035) had a statistically significant influence on periodontal disease [Table 6].{Table 6}

The result of binary logistic regression analysis of the presumed oral mucosal lesion influencing factors such as gender, nature of work, nicotine dependence for smoking and smokeless tobacco indicated that only nicotine dependence for smoking (P = 0.008) and smokeless tobacco (P < 0.001) had a statistically significant influence on oral mucosal lesion [Table 7].{Table 7}


This cross section study was unique in assessing the association of demographic characteristic, occupational stress, nicotine dependence to smoking and smokeless tobacco with oral health status among public transit workers. Our study revealed high percentage of males with tobacco use and high prevalence of periodontal disease and oral mucosal lesions among them. Similar findings were reported by Radi et al. who reported high job strain was related to smoking in males but, in females had no effect on tobacco use.[21] In our study, considering the small number of female smokers, a definite statement cannot be made in this regard. The oral mucosal lesions were more prevalent among males than among females. This difference may be due to the fact that a large number of men are reported to have the habit of smoking and chewing tobacco and with mixed habits; similar findings were reported in previous studies.[30] Our study results reported high prevalence of periodontal disease with level of nicotine dependence which was in agreement with the findings of Shizukuishi et al., who reported significant association between tobacco use and periodontitis among Japanese factory workers.[31] These changes can be explained due to alteration in microflora and negative effect on the host immune response. A high statistical significant association between oral mucosal lesions and level of nicotine dependence was also observed in our study. Tobacco use is one of the most important risk factor for the development of oral mucosal lesions including potentially malignant lesion and cancer.[32] Various studies have reported that smoking and chewing of tobacco and betel quid act synergistically in oral carcinogenesis and that person with mixed habits forms substantially high-risk populations.[33]

In the present study high occupational stress was associated with high prevalence of periodontal disease which was in agreement with the findings of Linden et al. who reported a significant relationship between work stress and periodontal health status.[13] These findings give support to the theory that stress has a relatively nonspecific effect since it is associated with a variety of diseases including periodontal disease.[34],[35] On contrary, Marcenes and Sheiham reported lack of association between work stress and periodontal health status which they explains due to presence of confounding factors which may interact with stress and can leads to spurious association.[11]

The present study has limitations typical of a cross-sectional research that cannot ascertain causality. Longitudinal studies provide valuable information compared to the cross sectional studies but longitudinal studies are difficult to organize and more time consuming than cross sectional studies. Further, because data were collected in face-to-face interviews, the presence of another individual at these interviews (e.g., co-workers, senior officers) may have been enough to distort the results. Because “social desirability bias” involves the systematic distortion of responses in a certain direction, contorted marginal distributions in the participants' responses must be considered when looking at the results. In our study, we have not taken the habit of alcohol in consideration which can act as a potential confounder. The oral mucosal lesions were not differentiated into the potentially malignant lesion and conditions in our study due to limitations and shortage of diagnostic equipment. These differentiations can be considered in further studies to correlate different conditions with level of nicotine dependence and other factors. Despite these shortcomings, even though the study was conducted among public transit workers of one city, the sample size is fairly adequate and represents the overall pattern of adverse addictive tobacco habits and occupational stress among public transit workers. These results can be applied to Indian population as a whole. The study found some important and often neglected correlates of ill effects of tobacco and oral health. Antitobacco advocacy offers an approach in improving both general and oral health. Banning tobacco usage shifts the responsibility for health from the formal healthcare system to individuals. Successful and effective implementation of anti-tobacco acts and rules lies within communities and decision-makers at all levels of society. A crucial need for strict implementation of antitobacco act is clearly evident in the present era.


In the present study poor oral health status is associated with occupational stress and nicotine dependence. As these factors have individual as well as synergistic effect on oral health. A multi-risk approach and work place interventions to reduce job stress, psychotherapy sessions, and counseling for already established nicotine dependence and motivational oral health education programs and strategies to promote oral health are the need for status quo.


The authors would like to thank Dr Shuhaib.A. Rahman, Dr. Rohini Sharma and Dr. Ritu Maiti for their valuable contributions and support.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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