Prevalence of Tobacco and Areca-nut Use and Awareness of Its Harmful Effects among Non-academic Staff at Faculty of Dental Sciences, University of Peradeniya

Prevalence of oral cancer and oral potentially malignant disorders (OPMDs) is a major problem in Sri Lanka. According to the National Cancer Registry 2008, oral-pharyngeal cancers were 12.8% of all reported cancers in Sri Lanka and carried the highest mortality rate among all cancers; 3 deaths per day [1]. Currently, the incidence has risen to 15.8%. The well-known risk factors for this are usage and inadequate awareness on the harmful effects of tobacco and areca nut (AN) among the public. Apart from oral cancers and OPMDs, tobacco and AN are also major risk factors for cardiovascular diseases, chronic obstructive pulmonary disease, certain non-oral cancers and reproductive disabilities. Tobacco is the single most preventable cause of death Abstract

Introduction smoking etc. The pattern varies with geographic area, gender, socio-economic status and age.
Prevalence of SLT use in Sri Lanka is rising each year. One of the main reasons is the misconception that using SLT is less harmful or safe compared to smoking types [5]. According to 2015 STEPS survey in Sri Lanka, more than one fourth of the males (26.0%) and nearly 5% of the females are reported to be currently using SLT. This is more prevalent among older age groups. Nearly 12% of the current users are daily users. SLT is predominantly consumed as part of the betel quid (betel leaf filled with scraped AN, lime and tobacco) but it may be consumed in other methods such as, dried tobacco in the form of snuff and snus.
The usage of AN is indigenous to South Asian countries like Sri Lanka and the pacific region. AN, also known as betel nut is the fourth most common psychoactive substance in the world after caffeine, alcohol and nicotine [6]. It contains 4 types of carcinogens, which cause OPMDs and oral cancer. At present, the usage of commercially prepared flavored AN products such as gutka, panmasala, mawa etc are also increasing.
A gazette notification has been issued by the Minster of Health of Sri Lanka under the provisions of National Authority of Tobacco and Alcohol (NATA) act banning the manufacturing and selling of smokeless tobacco products [7]. Additionally, Ministry of Public Administration has also issued an internal circular which bans the use of smokeless tobacco products within the government institutions. University Grants Commission has adopted this circular and issued an internal circular to all state universities in Sri Lanka coming under the purview of UGC banning the use of SLT in state universities by its employees and others [8].
Hence, this study was conducted to determine the prevalence of tobacco and AN use among the nonacademic staff of the Faculty of Dental Sciences, University of Peradeniya which plays a major role in the fight against oral cancer through prevention, cessation of tobacco and AN use and awareness of its harmful effects.

Materials and Methods
Following the ethical approval from the Ethics Review Committee of the Faculty of Dental Sciences, University of Peradeniya, an institutional based cross sectional study was conducted among 108 participants of the nonacademic staff at the Faculty of Dental Sciences.
A self-administered questionnaire was developed in English, forward and backward translations were done to Sinhala and Tamil languages. Content validation for this questionnaire was carried out with the help of experts in Community Dentistry. Pre-testing of questionnaires was conducted among ten supporting staff members of the Dental Hospital, Peradeniya. The questionnaire included sections to collect socio-demographics, reasons for initiation, form of tobacco/AN used, frequency and duration of consumption of tobacco/ AN use and their awareness on harmful effects of tobacco/AN consumption. Additionally, questions regarding the awareness of tobacco/AN use were also included (appendix 01) and each correct answer was given a score of 1 point. The total score was considered to evaluate the awareness (0-2: unaware, 3-6: aware).
A name list of non-academic staff of the faculty was collected from administration and the questionnaire was sent to all the nonacademic staff members through internal mail together with a courier's letter stating the objectives & instructions, information sheet and a return envelope. A reminder was sent to all after 2 weeks and the questionnaires were collected. Data were analyzed using Statistical Package of Social Sciences (SPSS) version 21.0.

Results
The analyzed sample consisted of a nearly equal male: female distribution. Age-wise distribution showed that 19%, 61% and 20% were 18-30, 31-50 and 51-70 years respectively. Majority (53%) of them had completed their education up to G.C.E Advanced level while another 30% had also done higher studies ( Figure 1).
The results revealed that only 5 (4.6%) out of the 108 participants had any form of tobacco or AN use; tobacco smoking-2, betel quid with tobacco and AN-3. When considering their socio-demographics, all were males (p=0.023) and 3 of them were between 31-50 years while remaining 2 were from the 51-70 year age group. Another significant finding was that 1 had no education while another 2 had completed up to G.C.E Ordinary level only (p=0.017). However, 2 of the betel quid chewers had completed up to G.C.E. Advanced level and followed diplomas despite having these harmful risk habits.
Awareness among the non-academic staff revealed that only 48% of the sample had a satisfactory level of awareness regarding the harmful effects of risk habits like betel quid chewing and tobacco smoking. When comparing the awareness with the education level, both participants without any education were unaware while only 38% and 47% of those who had studied up to G.C.E. Ordinary and Advanced levels were aware of the harmful effects. However, majority (61%) who had completed tertiary education had a satisfactory awareness. Table 1 shows the association of age, gender and education level on the awareness of harmful risk habits like betel quid chewing and tobacco smoking.
When separate statements on awareness were analyzed the results revealed that less than 30% were aware about the unhealthy effects of AN use and how quitting tobacco and AN improves the health (Table 2).
Finally, whether they had received information on the harmful effects of tobacco/AN was questioned and the results revealed that 75% of them had received information whereas only 5% had not. Unfortunately, about 20% had not responded to this question. Many of them had received information through multiple means which included lectures, posters and leaflets mainly. on the harmful effects of these tobacco/AN products.
Accordingly, the current study findings revealed that the prevalence of tobacco/AN use among them was minimum (4.6%). According to the National Oral Health Survey of 1994/1995 [9], the prevalence of betel quid use was 33.78% among 35-44 year olds and 47.7% among 45-74 year olds with an overall prevalence of 40.5% among 35-75 year olds which is considerably high compared to the current study [10]. The Asian betel quid consortium of South and East Asia carried out a prevalence study on betel quid chewing across six Asian countries in which Sri Lanka showed a prevalence of betel quid with tobacco as 6.4% among men and 3.2% among women. The study in Sri Lanka was conducted among 1,072 subjects from three provinces of Gangawata Korale, Udunuwara, and Yatinuwara with a response rate of 99% [11]. This shows a similar percentage prevalence to our current study.
The awareness of the harmful effects of these risk

Discussion
Sri Lanka is one of the countries in the South East Asian region which has a high prevalence of betel quid chewing which includes both tobacco and AN in the quid. These are well known risk factors for oral cancer and other OPMDs. Oral cancer is ranked first among all cancers in Sri Lankan males with a prevalence of 18.4% [1]. However, it is a preventable disease through risk habit intervention and awareness among the public. The Faculty of Dental Sciences, University of Peradeniya is a main centre which plays an active role in this fight against oral cancer and currently has established a Centre for Research in Oral Cancer which includes both community level awareness and prevention programs for oral cancer as well as laboratory based research. The non-academic staff at the faculty play a crucial role in these awareness programs and hence it is useful to evaluate the prevalence of these risk habits among them and understand their awareness   habits was also evaluated and the results revealed that only 48% of the sample has a satisfactory awareness on this subject. This finding contradicts the low prevalence of these habits. However, since betel quid chewing is an ancient traditional practice in Sri Lanka, it could be assumed that the change in culture has gradually reduced the habit of betel quid chewing. Unfortunately, recent research conducted among the younger generation reveal that the use of various new commercialized tobacco and AN products are increasing in addition to the traditional betel quid. At the Youth Tobacco Survey (GYTS) conducted in 2011 by Sri Lanka, the prevalence of current users of SLT among students was shown as 8.6% [12]. The prevalence was higher among males (13%) than females (4.1%). Similarly, the overall prevalence of betel quid with tobacco was 7.1% and higher among boys (11.3%) than girls (2.9%). However, other than betel quid with tobacco, both boys and girls used equally other commercial products of tobacco and AN; gutka, mawa, thul etc (2.5%).
The available literature reveals that the overall understanding and the level of awareness about health risks attributable to tobacco and AN is low among Sri Lankans. A cross-sectional community-based survey carried out in Sabaragamuwa province by interviewing 1029 subjects revealed that 32% were unaware that betel quid chewing was a risk factor for OPMDs and oral cancer, as were 65% for tobacco smoking. Unfortunately, an overall majority (76%) were not aware of any of the dangers inherent in the frequent use of AN according to that study [10]. Similarly, the current study also revealed that only 27% among the non-academic staff were aware about the unhealthy effects of AN use. However, the International Agency for Research on Cancer (IARC) has classified AN itself, even in the absence of added tobacco in betel quid, as carcinogenic to humans [13].
However, when questioned about whether they have received information on these harmful risk habits majority (70%) had responded positively despite their poor awareness. Hence attention should be given to the method of delivery of information in order for the ordinary public to understand the harmful risk habits in a simplistic manner and for them to share that knowledge with others as well.
These findings are useful in future awareness programs to adapt the content according to the various groups that are participating. Also, it is the responsibility of the faculty to conduct more awareness programs on tobacco and AN use and its harmful effects even among the non-academic staff, as they are an important stakeholder in this aspect.
In conclusion, even though, the prevalence of tobacco and AN use among the non-academic staff of the faculty is comparatively less, the awareness regarding its harmful effects like development of oral cancer and OPMDs is less satisfactory. Hence, it is important to conduct awareness programs on these harmful risk habits in a simple and innovative manner in order to increase the awareness of the harmful effects and enrich the non-academic staff of one of the leading centres, which is fighting against oral cancer to also become responsible stakeholders in it.

Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.

Conflicts of Interest
The authors declare no conflict of interest.