Work-Associated Stress and Nicotine Dependence among Law Enforcement Personnel in Mangalore, India.

PURPOSE
To investigate the work associated stress and nicotine dependence among law enforcement personnel in Mangalore, India.


MATERIALS AND METHODS
A cross-sectional questionnaire survey was conducted among law enforcement personnel in Mangalore, India. Demographic details, stress factors experienced at work and nicotine dependency were the variables studied. The extent of stress factors experienced at work was assessed using the Effort-Reward Imbalance scale (ERI). Nicotine dependence was measured using the Fagerstrom Test for Nicotine Dependence (FTND) and the Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST). Logistic regression was used for the statistical analysis.


RESULTS
Three hundred and four law enforcement personnel participated in the study, among whom 68 had the presence of one or more habits like tobacco smoking, tobacco chewing and alcohol use. The mean effort score was 15.8±4.10 and the mean reward and mean overcommitment scores were 36.4±7.09 and 17.8±5.32 respectively. Effort/Reward ratio for the total participants was 1.0073 and for those with nicotine habit was 1.0850. Results of our study demonstrated no significant association between domains of ERI scale and presence of habits but work associated stress was associated with the presence of one or more habits. Compared to constables, head constables had 1.12 times higher risk of having a nicotine habit.


CONCLUSIONS
Our study implies job designation is associated with nicotine habits. However, there was no association between work associated stress and nicotine dependence among law enforcement personnel in Mangalore.


Introduction
Law enforcement is a diverse job and law enforcement officers are empowered not only with the responsibility of maintaining public order but they also have to engage with citizens, identify and solve problems, and also respond to tens of thousands of calls from the aggrieved. Each day presents new challenges that require application of their skills in new and different situations. The law enforcement officers or the police possess one of the most stressful occupations in the world today and are ranked among the top ten most stressful jobs in the world (Nicoara and Amelia, 2012).
Chronic work-related stress is recognized as an imbalance between high efforts spent and low rewards received, which can be calibrated using the effort-reward imbalance (ERI) questionnaire. ERI is a well-justified psychometric measure of work-related stress available for comparative socioepidemiologic investigations ). The ERI model has been functionalised as a standardized self-report measure consisting of 22 Likert-R Priyanka 1 , Ashwini Rao*, Gururaghavendran Rajesh, Ramya Shenoy, BH Mithun Pai scaled items. This model defines three unidimensional scales: 'effort', 'reward' and 'overcommitment' rated on a five-point Likert scale (Siegrist et al., 1996a).
Nicotine dependence and its degree of dependence are determined by a single or combination of factors like individual, genetic and psychosocial factors. Certain psychosocial factors like occupational stress and poor quality of life, might have an influence on the initiation and extent of smoking (Schmidt, 2010). The estimated number of hardcore adult smokers in the South-East Asian countries was 31.1 million, the absolute number of hardcore smokers was higher in India than Bangladesh and Thailand (Kishore et al., 2013). The strength of nicotine dependence can be determined by The Fagerstrom Test for Nicotine Dependence (FTND). It is an economical, non-invasive way to rapidly assess nicotine dependence. It helps the clinician determine the degree to which a patient is nicotine dependent (Fagerstrom et al., 1978). The Fagerstrom Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST) is a modified form of Fagerstrom Test for Nicotine Dependence (FTND) used to find the degree of nicotine dependence among smokeless tobacco users (Ebbert et al., 2006). In India, tobacco consumption is both by smoked and smokeless forms, commonly used smoked forms are of beedis and cigarettes (Chandra et al., 2005). High levels of nicotine dependence among smokers could probably be due high levels of job stress, which may lead to difficulty in smoking cessation leading to cancer (Ota et al., 2004;Tanriover et al., 2013;Nakao et al., 2013).
Many people face stress in their professional or personal life, whereas law enforcement officers have high level of stress not only due of their nature of work, but also because of the environmental influences linked with their work (Nicoara and Amelia, 2012). These daily hassles coupled with their operational duties can have impacts on their health. Distress and other health problems might occur as a result of not coping with their serious operational duties (Berg et al., 2006). Degree of tobacco consumption might shed some light on potential stress at work .
Inspite of extensive literature search, we could not find any studies of work associated stress and Nicotine Dependence among law enforcement officers in India. Therefore this study was conceptualized to determine work associated Stress and nicotine dependence among law enforcement personnel in Mangalore, India

Materials and Methods
The study was conducted among law enforcement personnel in Mangalore, Dakshina Kannada district, which is located along the western coast of India. The study design was a cross-sectional type using a self-administered questionnaire. Data regarding age, gender, address, number of years in this occupation and tobacco consumption was collected from all participants. The Effort-Reward Imbalance (ERI) scale, a 22 item questionnaire: extrinsic efforts (5 items), occupational rewards (11 items), and overcommitment (6 items) (Siegrist et al., 1996a;Siegrist et al., 1996b) was used to measure stress. The Fagerström Test for Nicotine Dependence (Fagerstrom, 1978;Heatherton et al., 1991) and The Fagerström Test for Nicotine Dependence-Smokeless Tobacco (FTND-ST) (Ebbert et al., 2006) were used to measure nicotine dependence. Ethical approval was obtained from the Institutional Ethics Committee (Protocol Ref No. 14057/2014). Translation and adaptation of the questionnaire to the local language (Kannada) was done using forward-translations and back-translations. The validity and reliability of the questionnaire was tested by a pilot study on 10 respondents who were representative of the study subjects but not included in the study (k = 0.85). Each participant was given 10 minutes time to fill the questionnaire. If any participant was not present in the first visit, a second visit was made.

Statistical analysis
The data was entered in the SPSS software (version 11.5) for statistical analysis. The analysis was done using one way analysis of variance (ANOVA) and Tukey

Results
Demographic data of the participants is given in Table  1. A total of 304 participants were included in the study and among them 66% were between 20-39 years of age, 15.5% were females and 71% were constables. Presence of one or more habits like tobacco smoking and tobacco chewing were reported by 34 (11.2%) participants, whereas 58(19.1%) reported the presence of alcohol habit. The prevalence of habit was found to be higher among males (26.1%) compared to females (2.1%) and also among those who had more than 10 years' experience in this profession (26.3% Vs 18.2%). Among the constables who formed 71% of the population, 43 (19.9%) reported the presence of habit. Among the 19 who reported the smoking habit, 8 were head constables and 10 were constables and among the 15 who reported smokeless tobacco habit, 5 were head constables and 7 were constables. (Table 1) Mean Effort Reward Imbalance (ERI) scores and Effort Reward (ER) ratio of total population was found to be 66.11±12.28 and 1.0073 respectively. The mean effort score was 15.83±4.10, mean reward score was 36.44±7.09 and mean over commitment score was found to be 17.84±5.32. The ER ratio for those with nicotine habit was 1.0850 and for those without the nicotine habit was 0.9991. For Effort Reward (ER) = 1 the person reports one effort for one reward, for ER< 1 there are less efforts for each reward, and for ER >1 the person reports more efforts for each reward. The mean effort was more among those who had the absence of habit, but the mean reward and mean over commitment were more among those who had the presence of habit. (Table 2) Based on the ERI model, along with the effort (workload or other job demands) put in by the employees, it the perceived imbalance between the efforts made and the reward received that leads to strain. Also, work that required high levels of effort but resulted in lower rewards could be the source of negative emotions in the subjects. This might be accompanied with continuous strain reactions .
When we calculated the nicotine dependence level based on FTND, we found that 53.8% of smoked tobacco users had low nicotine dependence and 30.8% had high nicotine dependence, whereas among smokeless tobacco users, 30% had moderate and 70% had high nicotine dependence. (Table 3) When we compared demographic variables like age, education and number of years in the occupation, we found that although these variables were not significantly associated with the habit of smoking, tobacco chewing or alcohol consumption, job designation was found to be significantly associated with alcohol consumption. (Table 4) The logistic regression model was constructed with habits as the dependent variable and job designation,     years of experience and Effort Reward Imbalance Scale as the independent variables. There was a significant relationship between nicotine habit and job designation among constables and head constables, but there was no significant difference among the other cadre like inspectors and sub-inspectors. Compared to constables, head constables had 1.12 times higher risk of having the nicotine habit. (Table 5)

Discussion
The present study tried to explore the work associated stress and nicotine dependence among law enforcement personnel in Mangalore, India.
The prevalence of tobacco smoking in our study was low (6.3%) compared to other studies (Vitavasiri et al., 2009;Sujatha et al., 2012;Thakur et al., 2013;Hock et al., 2014;Alsanosy 2014). When we compared our findings with (Mallikarjun et al., 2014) that of a study done in the same geographic area among bus drivers, we found the prevalence of tobacco smoking to be very low in our group compared to the findings among bus drivers.
In our study we used the ERI scale to measure stress and found that the mean effort domain was higher among those who had no habit, but mean reward domain and mean overcommitment domain were higher among those who had the habit. Few studies (Siegrist et al., 1990;Bosma et al., 1998) have shown that cardiovascular health, subjective health, mild psychiatric disorders and other reported symptoms could be due to the risk factors like high effort and low reward at work.
In the present study the mean ERI score was 66.11±12.28, which was found to be different from a previous study (Hunnur et al., 2014) on law enforcement personnel in 4 districts of Karnataka, which showed high stress with a mean score of 175.54. Previous studies (Head et al., 2004;Hintsa et al., 2015) have shown that ERI scale had an effect on alcohol dependence and also on cardiovascular disease risk. But in the present study there was no significant relation between overcommitment and habits like smoking, tobacco chewing and alcohol consumption which predispose to cardiovascular disease.
In the current study FTND and FTND-ST showed no significant association with ERI scale, as very few participants answered the nicotine dependence questionnaire. Thirty four participants reported the presence of tobacco habit, out of which 19 participants had habit of tobacco smoking and 15 participants had tobacco chewing habit. Among those who responded to FTND, 53.8% had low nicotine dependence and 30.8% had high nicotine dependence for tobacco smoking and among those responded to FTND-ST 30% had moderate and 70% had high dependence for smokeless tobacco.
Although, in the present study overall ERI scale did not show any significant relation with nicotine dependence, individual domains of effort and reward had shown significant relation with habits like smoking, tobacco chewing and alcohol consumption. In contrast to present study other studies (Garbarino et al., 2013;Kouvonen et al., 2005) have shown an association between work stress and smoking. However these studies were conducted among special force police officers in Italy and in public sector employees, who had a different life style and work load. The findings of the present study are similar to the data form the Cologne Smoking Study (Schmidt et al., 2010) which did not show any association between job stress and nicotine dependence using FTND and ERI scales.
Job designation was significantly associated with alcohol consumption, but it did not show any relation with smoking, tobacco chewing and ERI scale. The main limitation of the present study is that of a potential bias due to non-response (response rate of 76%), as with any population based survey. However, the participants are representative of all members of the law enforcement personal in Mangalore.
In conclusion, our study shows that although job designation is associated with habits, it is not associated with nicotine dependency. An inherent limitation with any questionnaire study design, that the respondents may not tell the truth due to social desirability or regulatory obligations also needs to be considered.