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Ann. psychophysiol. 
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APP| Published By AEIRC| https://doi.org/10.29052/2412-3188.v8.i1.2021.34-42 
 

 
 
Original Article                                                                                  

Behavioral and Psychological attributes of 
the smokeless tobacco consumers in Karachi 
Sadia Aslam1, Ahad Javed2, H. M. Usman1, Lubna Naz1 & Samia Mushtaq1 
1Department of Physiology, University of Karachi, Karachi-Pakistan.  
2Karachi University Business School, University of Karachi, Karachi-Pakistan.  
 

Abstract 
Background: Prevalence of smokeless tobacco (ST) consumption has been 
observed worldwide in the twentieth century, especially in Asian and African 
countries, with estimated 47% ST consumers in Pakistan. Therefore, the present 
study aimed to investigate the potential rationale of individuals for ST-initiation 
and various behavioural and psychological attributes of ST-consumers. 
Methodology: The study was conducted in an underprivileged area of Surjani 
town, West district of Karachi, Pakistan. 150 study participants were selected for 
the study, in which consumers of the current ST consumers (Betel nuts, Gutka and 
Oral Snuff) were recruited. In contrast, the individuals not taking ST served as 
controls. Individuals with smoking, any other type of addiction, medications for 
any chronic disease (hypertension, diabetes), or having any other 
behavioural/psychological problems were excluded from the study. A structured 
questionnaire was designed to evaluate the level of stress (Modified Hassles scale), 
addiction, and nicotine dependence. The participants were explained about the 
purpose of the study and the interviews were conducted by personal meet-up in 
their homes. Data was collected and analyzed via SPSS version 16.0. 
Results: Curiosity and peer pressure appeared to be among the most important 
factors for ST consumption initiation. 25% of ST consumers were found to be at the 
end stage of addiction, while 36% categorized to be in the second stage of 
addiction. Irritation, Anger, Headache and laziness were among the most 
prevalent types of feelings experienced by the study participants. The reduced 
stress levels in ST consumers compared to the controls were due to their euphoric 
condition attributed to the ST. Approximately 30% of the consumers were 
categorized to have an increased risk of obesity. 
Conclusion: As a readily available and affordable addictive agent, smokeless 
tobacco consumption has been raised in Pakistan more than in the west. Smokeless 
tobacco consumption-initiation has been linked to increased curiosity and peer 
pressure. 
 

Keywords 
Smokeless Tobacco, Rationale, Peer Pressure, Addiction. 

 

 

 

 

Citation: Aslam S, Javed A, Usman HM, 
Naz L, Mushtaq S. Behavioral and 
Psychological attributes of the smokeless 
tobacco consumers in Karachi. APP.2021; 
8(1):34-42 
 
Corresponding Author Email: 
samtaq.physio@gmail.com 
 
DOI: 10.29052/2412-3188.v8.i1.2021.34-42 
 
Received 23/11/2020 
 
Accepted 25/05/2021 
 
Published 01/06/2021 
 
Copyright © The Author(s). 2021 This  
 is an open access article distributed 
under the terms of the Creative Commons 
Attribution 4.0 International License, 
which permits unrestricted use, 
distribution, and reproduction in any 
medium, provided the original author 
and source are credited.  
 

 

Funding: The author(s) received no 
specific funding for this work. 

Conflicts of Interests: The authors have 
declared that no competing interests 
exist. 
 

https://doi.org/10.29052/2412-3188.v8.i1.2021.
http://creativecommons.org/licenses/by/4.0/)
http://creativecommons.org/licenses/by/4.0/)


 
 
 

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Introduction  
The prevalence of smokeless tobacco (ST) 
consumption has been observed worldwide 
in the twentieth century, especially in Asian 
and African countries. ST product 
consumption has been linked to more than 
50% risk of oral cancer in Asian countries1. 
The worldwide death rate owing to tobacco 
consumption is 5 million per annum, and 
this rate is higher than the rate of people died 
on account of AIDS, drug abuse, road 
accident, murders and suicides2. Easy 
accessibility and affordability are the main 
factors for increasing smokeless tobacco 
among middle-class individuals3. This case-
control study was formulated after having a 
gross observation of smokeless tobacco (ST) 
consumers' lifestyle. In Pakistan, 23.9 million 
adults are involved in using different forms 
of tobacco, in which 9.6 million adults use 
smokeless tobacco4. A huge multi-ethnic 
population of Karachi was reported to be 
involved in Gutka consumption (79.2%), 
Betel Quid (34.4%), Areca nuts (21.6%), and 
Naswar (12%)5. The consumers have 
reported various reasons regarding 
consumption of any drug, including peer 
pressure, accidental, stress, boredom, 
curiosity & maybe for no reason5. 
 
Moreover, a misconception existed among 
people about the curative effect of smokeless 
tobacco against toothache, headache & 
stomach ache3. Rozi and Akhtar reported 
that age and socio-economic status are the 
causes of change in tobacco use2. Besides age 
and socio-economic condition, using 
smokeless tobacco is also affected by ethnic 
origin and gender1. ST-addiction tends to be 
initiated by regular consumption in 
individuals taking it earlier for medicinal 
purposes.  
 
The complex nature of addiction-
phenomenon ranges from the etiological 
factors that interfere with the molecular 

mechanisms to the individuals' social 
interactions. Drug addiction is a series of 
complex molecular interactions in drug-
sensitive neurons, with consequent altered 
neuronal properties, activities and 
metabolism that finally results in altered 
behaviour like craving, dependence, 
tolerance and sensitization6. Nicotine, being 
the cardinal addictive constituent in tobacco 
products, interacts with neuronal nicotinic 
acetylcholine receptors (nAChRs)7. Since 
nicotine increases dopamine, 
norepinephrine, acetylcholine & serotonin 
by interacting with central nervous system 
receptors8, nicotine withdrawal causes 
impaired cognitive performance9. 
 
Mental stress is a situation of psychological 
illness. It can be due to any reason such as 
family conflict, loss of the relationship, loss 
of child or death of a close family member. If 
the stress is more severe or repeated, it will 
induce more critical situations that will be 
uncontrollable or unpredictable10. People 
have linked drug use to deal with stressful 
situations, and anxiety-relief10 and stress 
cause a craving for a particular drug11,12. 
Hence, psychological stress predisposes 
individuals to tobacco consumption. The 
diversified nature of individuals' 
sociocultural and biological attributes in 
various countries has justified the 
heterogeneity among the ST consumers' 
behaviors13. Despite the high prevalence of 
ST consumption in the South-Asian region, 
there is a scarcity of the reported data on the 
behavioural effects of ST consumption, as 
well as the present study also presents the 
level of addiction and stress level for daily 
Hassles of the ST consumers which, to the 
best of our knowledge, has not yet been 
investigated in the population of Surjani 
town, West District of Karachi, Pakistan. 
 
Therefore, the present study aims to 
investigate the potential rationale of a person 



 
 
 

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for ST-initiation and various behavioural 
and psychological attributes of ST-
consumers.  
 

Methodology 
The study was conducted in an 
underprivileged area of Surjani town, West 
district of Karachi, Pakistan. A total of 150 
current ST consumers (Betel nuts, Gutka and 
Oral Snuff) were recruited. In contrast, the 
individuals not taking ST served as controls. 
Individuals with smoking, any other type of 
addiction, medications for any chronic 
disease (hypertension, diabetes), or having 
any other behavioural/psychological 
problems were excluded from the study. 
 
Participants were selected as per the criteria 
as mentioned above. The techniques of data 
collection in this study were based on a 
structured questionnaire. The questionnaire 
was designed to evaluate three significant 
constructs: the Level of stress14, addiction, 
and nicotine dependence15. A modified 
Hassles scale was used to assess the stress 
levels of the study participants. It is a 51-item 
scale measuring the intensity of life 
experiences; each question had one of the 
four responses (Not at all part of life =1, only 
slightly part of my life = 2, distinctly part of 
my life = 3, and Very much part of my life 
=4)14. The scale to evaluate the level of 
addiction is a 20-item scale with 
dichotomous responses (Yes = 1, No = 2). 
The items of the tests mentioned above were 
also validated using Pearson’s Correlation 
Coefficient. Consumers’ Rationale for ST 
initiation was evaluated via pre-formulated 
questions reported by Baig and associates 
regarding the reasons for ST initiation. The 
same was inducted in the questionnaire for 

determining the highest prevalence of 
reason for which people start taking ST5.  
 
Informed consent was taken, the participants 
were explained about the purpose of the 
study and interviews were conducted by 
personal meet-up in their homes. Data was 
collected and analyzed via SPSS version 16.0.  
ST-Quantification was done via 
commercially available packs of Betel nuts, 
Gutka and Oral Snuff were considered for 
this study, and their mass was obtained 
through Shimadzu Libror AEL-200. 
 
ST Consumers’ Nicotine Dependence was 
assessed using Fagerström Test for Nicotine 
Dependence-Smokeless Tobacco (FTND-
ST)15. Self-generated questions were used to 
determine the consumers’ quitting-
willingness and feeling upon craving. 
Participants were also categorized based on 
their addiction status. Mental stress was 
assessed using Hassles scale14,16. 
 

Result 
After carrying out this study with a good 

level of cooperation of the study 

participants, various significant findings 

were made. The results are as follows: 

 

Out of all ST consumers, 17% participants 

consume more than 5 sachets (i.e., > 9.34 

grams) of Betel nuts, 15.2 % participants 

consume 1 to 3 packets (i.e., 31.87 grams to 

95 grams) of Gutka and 15.2 % participants 

consume lesser than 1 packet (i.e., < 29.27 

grams) of oral snuff in a day. Curiosity was 

the most common reason for starting ST 

consumption with the involvement of 50% of 

participants in it while 30.5% start it due to 

peer pressure (Figure 1).  

 



 
 
 

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Figure 1: Rationale of smokeless tobacco initiation. 

 

Evaluation of the level of addiction was tested using a 20-item scale. The reliability of the test was 

estimated using Cronbach alpha. The reliability was found to be excellent (α = 0.776)17. The items 

were also validated using Pearson’s correlation coefficient, it showed significant values for the 

items (p<0.05). 

 

 

 
Figure 2: Level of addiction of the smokeless tobacco consumers. 

 

Of the total, 25.53% of ST consumers were found to be at the end stage of addiction while 36.17% 

ST consumers belonged to the second stage of addiction, with 29% belong to the age group 26-35 

and chew Gutka while 17% were betel nuts consumers and belong to the age group 15-25 (Figure 

2). 

 

No addiction
4.25%

Probably 
Addiction 

10.64%

Early stage
23.40%

2nd stage
36.17%

End stage
25.53%

Stress, 5.55%

Boredome, 
11.11%

Curiosity, 50%

Peer pressure, 
30.50%

Unconciously, 
2.77%



 
 
 

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Figure 3: BMI of smokeless tobacco consumers. 

 

Around 42.55% of the ST consumers had normal BMI, 19% were obese, while 30% were 

Overweight (Figure 3). Evaluating the stress level of the study participants, the Hassles scale was 

used. The reliability of the test was evaluated using Cronbach alpha (α = 0.909), which is an 

excellent value endorsing the reliability of the test17. The items of the scale were also validated 

using Pearson’s correlation coefficient and it showed significant values (p<0.05). Based on the 

final scores of the test, the participants were categorized. 70% of the ST consumers were having 

average stress, 7% were having high stress. 

 

 
 

Figure 4: Number of participants with average mental stress versus category of subjects. 

 

When participants with average stress levels were compared, 31% controls, 27% Gutka 

consumers, 21% betel nuts consumers and 19% snuff consumers were found to have mental 

stress. It showed that most of the controls were mentally stressed while tobacco consumers had 

reduced mental stress due to their euphoric condition attributed to the ST (Figure 4). 

 

Underweight 
8.50%

Increased but 
Acceptable risk

42.55%
Increased Risk

30%

High Risk
19%

19%

21%

27%

31%

Snuff

Betel Nuts

Gutka

Controls



 
 
 

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Figure 5: Feeling of ST consumers upon not having tobacco. 

Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco showed 35% of the study 

participants were highly nicotine dependent, whereas 20% were found to be less nicotine 

dependent. Irritation, Anger, Headache, and laziness were among the most prevalent types of 

feelings experienced by 36%, 22.2%, 16.6% & 13.8% of the study participants, respectively. 

 

 

Discussion 
There are several types of tobacco, but in this 
study, the consequences of a few of them are 
analyzed, such as Betel nuts, Gutka & Oral 
Snuff. Betel nuts are a type of tobacco being 
used with the fourth highest prevalence in 
the world18. Nicotine tobacco is used for the 
preparation of Gutka19. Nicotine is a potent 
addictive drug that is consumed to improve 
cognitive abilities9,20. Nicotine is a potent 
sympathomimetic drug, thus causes 
blockade of peripheral nicotinic receptors 
and stimulates the sympathetic nervous 
system increases the release of epinephrine, 
eventually heart rate, blood pressure & heart 
contractility21. Nicotine intake in regular 
smokers and regular users of smokeless 
tobacco is the same22. Smokeless tobacco 
contains more than 30 types of cancer-
causing agents that include volatile or 
tobacco-specific nitrosamines, nitrosamino 
acids, polycyclic aromatic hydrocarbons, 
aldehydes and metals1. 
 

 
According to Dass, Jaganmohan, auto 
drivers were found to be the frequent 
consumers of ST19. Ali et al., reported that 
40% of people use ST by getting inspired by 
media advertisements, their friends or 
colleagues pressurized 31% to use ST23. In 
comparison, over 40% people use it to get rid 
of common health problems. Imam et al., 
reported comparable findings3. Similarly, 
Baig et al. also reported peer pressure to be 
one of the most common reasons for ST 
consumption5; however, other reasons such 
as accidental involvement, stress, boredom, 
and curiosity were also reported. In our 
study, curiosity was found to be among the 
most prevalent reasons for ST consumption 
(Figure 1), with other important reasons 
being peer pressure (30.5%), boredom (11%), 
and to get rid of mental stress (5.5%), while 
only 2.7% participants started consuming it 
at an immature age when they even did not 
know what it was, these reasons were also 
determined by Baig et al. with different 
prevalence rate5. 

Irritation, 36%

Laziness, 
13.80%

Anger, 22.22%

Headache, 
16.66%

Body pain, 
2.77%

Craving for it, 
8.33%



 
 
 

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In this study, the ST consumers are found to 
be at various stages of addiction. Among 
these stages, only 4% of consumers were 
found not to be addicted, they consumed ST 
for the fun of time being, and they could quit 
that anytime, about 11% of consumers were 
probably addicted, 23% consumers were at 
the early stage of addiction, i.e. addiction 
had not made significant changes in their 
lifestyle, and they did not experience a 
severe feeling of craving, 36% ST consumers 
were at the second stage of addiction, shown 
in Figure 2. Here the important point is that 
among these 36% people, 29% individuals lie 
between the age 26-35 years and they 
consume Gutka and 17% of them were betel 
nuts consumers and belonged to the age 
group 15-25 these individuals tried their best 
to keep a sufficient amount of ST with them 
every time to avoid any extreme situation; it 
is a part of their daily life. 25% of ST 
consumers are at the end stage of addiction; 
their addiction was so high that if they did 
not get ST when craving, it resulted in 
extreme anger or harsh behaviour. It was 
noted in the consumers of the second stage 
that the individuals who were addicted to 
betel nuts during the age 15-25 were more 
susceptible to move towards more complex 
and more potent addictive agents (i.e. 
Gutka) after few years. Similarly, when their 
neurons did not have the consistent euphoric 
feeling upon having the same addictive drug 
for an extended period, they may move to a 
much harder addiction.  
 
Reduction in the weight gain process has 
been linked to Snus (a kind of ST) 
consumption24. However, our results have 
shown a positive correlation between BMI 
and ST consumption with 29.8% and 19.15% 
consumers were overweight and obese, 
respectively (Figure 3), and only 8.5% were 
underweight. 
 

According to Sinha10, stress is a situation of 
psychological illness. It can be due to any 
reason such as family conflict, loss of a 
relationship, loss of child or death of a close 
family member. If stress is more severe or 
repeated, it will induce more critical 
situations that will be uncontrollable or 
unpredictable; hence, he declared in his 
study that people use addictive drugs to deal 
with stressful situations to get relief from 
tensions. Sinha11, Cleck and Blendy12 also 
showed a correlation between addictive 
drug consumption with mental stress, 
stating that he is more likely to use addictive 
drugs if an individual is psychologically 
stressed. Stress induces a craving for a drug. 
Comparable results were obtained in our 
study. The participants without any 
addiction have comparatively higher mental 
stress than betel nuts, Gutka and Snuff 
consumers (Figure 4).  
 
The number of individuals with average 
mental stress levels gets lower as we move 
towards the harder addictive agent. The 
primary purpose of ST consumption 
appeared to be a euphoric condition. It was 
also observed that with the increase in age, 
the willingness of an individual to quit 
tobacco decreased. It is commonly observed 
that as age increases, the habits of an 
individual become much stronger. Thus, if a 
person is addicted to a specific drug for 
about more than 20 years, it can be 
understood by the facts that how difficult it 
could be for an ST consumer to quit 
consuming tobacco. In this study, we asked 
ST consumers about whether they want to 
stop consuming ST or not. It was found that 
the individuals with lower age have the 
willingness to quit tobacco, while as the age 
of consumer increases, the individuals could 
not even think of quitting. Thus, desire to 
quit tobacco consumption had an inverse 
relationship with age. 
 



 
 
 

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Mansvelder and McGehee described that 
craving is a situation that occurs because of 
addiction which is a series of complex 
molecular interactions in neurons that are 
sensitive to it7. As nicotine is an addictive 
agent in smokeless tobacco, withdrawal of 
nicotine intake causes impaired cognitive 
performance9. Thus, at the time of craving, 
every individual experienced a specific 
feeling. We have compiled the results of that 
feeling in this study according to our results 
irritation, anger, headache and laziness were 
found to be the feelings experienced by 36%, 
22.2%, 16.6% & 13.8% of the study 
participants, respectively. In contrast, the 
rest of the feelings were found in minor 
percentage, i.e. 8.33% of the participants 
experienced headache, and 2.77% of the 
participants encountered body pain or 
fatigue, shown in figure 5. Hence, irritation 
is the feeling being experienced by most of 
the ST consumers when they did not get ST 
when they crave for it.  
 

Conclusion 
As a readily available and affordable 

addictive agent, smokeless tobacco 

consumption has been increased in Pakistan 

more than in the west. Smokeless tobacco 

consumption-initiation has been linked to 

increased curiosity and peer pressure. 

Willingness to quit ST was found to be 

elevated at an early age in comparison to late 

ages. However, the restriction could be done 

via strategic implementation of promoting 

awareness regarding ST-detrimental effects 

on health and prohibiting ST sale at the 

government level. 

 

Acknowledgment  
The authors are thankful to the study 
participants for their cooperation in the 
study. 
 

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