Why do adolescents initiate and continue using tobacco and areca nut?: A qualitative study tracing pathways of use among school-going adolescents in Mumbai, India.

Tobacco and areca-nut use among adolescents has been reported from different parts of India. Multiple factors influence initiation of tobacco use among adolescents. Initiation of one product gradually extends to multiple products. Studies on initiation lack documentation of the pathways and experiences post-initiation which is required to holistically understand behaviour patterns of adolescents for planning timely intervention. This study was conducted to trace pathways and identify factors influencing the initiation and continuation of tobacco and areca-nut among adolescents.In this two-staged study, we conducted 14 focus group discussions (FGDs) with 166 adolescents studying in grades 7-9 (11-18 years) from six municipal schools in Mumbai, India. They had self-reported areca-nut or smoked or smokeless tobacco (SLT) use. Pathways of initiation were traced through in-depth interviews for 60 adolescents.Four multilinear pathways of use were identified: 1)areca-nut only, 2)areca-nut to tobacco, 3)initiation with SLT and 4)initiation with smoking. Raw or sweetened areca-nut, betel-leaf, gutka, masheri, mawa, hookah, cigarette, bidi and e-cigarettes were products reported to be used. Curiosity, easy access to tobacco products and normalization of tobacco use influenced initiation. Areca-nut acted as a precursor to tobacco use.Tracing pathways in tobacco use helped to understand reasons for initiation, influences in continuation of use and experiences of significance to the adolescents. Experiences of adolescents play a critical role in shaping the pathways of tobacco use. Understanding the pathways and influencers will further help to build effective health promotion communication, policies for sale to minors and school-based cessation interventions.Findings of the study provide an insight into unknown areas of information regarding products used by adolescents, their patterns of consumption, perceptions and their pathways of initiation and continuation of primary and secondary products.This will help in developing specific public health awareness messages, policies regarding packaging and sale of areca-nut to children and interventions targeted for the adolescents and their specific products of use not just in India but for the South-East Asia region as areca-nut and tobacco use among adolescents is common in the region. The exercise of tracing the pathways provides basis for cessation counselling among adolescents.