Survey on Knowledge and Attitudes Related to the Relation between Tobacco , Alcohol Abuse and Cancer in the Northern State of Sudan

Tobacco and alcohol use contribute significantly to mortality and morbidity in many countries (Lopez, et al., 2006; Begg et al., 2007). Tobacco use is the prime cause of death worldwide, resulting in millions of deaths annually, more than HIV/AIDS, tuberculosis and malaria (WHO, 2008). Tobacco smoking is an important public health concern worldwide leading to pulmonary disease, various cancers including those of the respiratory, digestive, and genitourinary systems, and certain forms of leukemia and premature death (Office of the Surgeon General, 2004). Socioeconomic factors influence tobacco use worldwide (Bobak et al., 2000). In the developed world, a strong inverse relationship between socioeconomic status and smoking exists such that the poorest and least educated populations are more likely to smoke (Laaksonen et al., 2005; Wipfli and Samet, 2009). In the Sudan, snuff, locally known as toombak, was introduced approximately 400 years ago. It is always processed into a loose moist form and its use is widespread in the country. Tobacco used for manufacture of the toombak is of the species Nicotiana rustica and the fermented ground powder is mixed with an aqueous solution of sodium bicarbonate. The resultant product is moist, with a strong aroma, highly addictive and its use is widespread particularly among males (Ahmed and Mahgoob, 2007). The use of Toombak has been stated


Introduction
Tobacco and alcohol use contribute significantly to mortality and morbidity in many countries (Lopez, et al., 2006;Begg et al., 2007).Tobacco use is the prime cause of death worldwide, resulting in millions of deaths annually, more than HIV/AIDS, tuberculosis and malaria (WHO, 2008).Tobacco smoking is an important public health concern worldwide leading to pulmonary disease, various cancers including those of the respiratory, digestive, and genitourinary systems, and certain forms of leukemia and premature death (Office of the Surgeon General, 2004).
Socioeconomic factors influence tobacco use worldwide (Bobak et al., 2000).In the developed world, a strong inverse relationship between socioeconomic status and smoking exists such that the poorest and least educated populations are more likely to smoke (Laaksonen et al., 2005;Wipfli and Samet, 2009).
In the Sudan, snuff, locally known as toombak, was introduced approximately 400 years ago.It is always processed into a loose moist form and its use is widespread in the country.Tobacco used for manufacture of the toombak is of the species Nicotiana rustica and the fermented ground powder is mixed with an aqueous solution of sodium bicarbonate.The resultant product is moist, with a strong aroma, highly addictive and its use is widespread particularly among males (Ahmed and Mahgoob, 2007).The use of Toombak has been stated

State of Sudan
Hussain Gadelkarim Ahmed to play a major role in the etiology of oral cancer in the Sudan and is suspected to be associated with neoplasm sof salivary glands (Elbeshir et al., 1989;Idris et al., 1994;1995).
Alcohol-abuse is a major cause of mortality and morbidity in both developed and developing countries (Santanu et al., 2012).Alcohol consumption can cause chronic diseases, such as cancer of the mouth, esophagus and larynx, liver cirrhosis, and pancreatitis, social consequences, such as road-traffic accidents, workplacerelated problems, family and domestic problems, and interpersonal violence (WHO, 2002).Therefore, alcohol consumption has been receiving more public or research attention in recent years.
The present study was undertaken with the objectives to identify the frequencies of tobacco use and alcohol intake among different population settings in Northern state of Sudan to provide data, so that it might be beneficial in planning, implementation, and evaluation of appropriate programmes for the elimination of these harmful habits.

Materials and Methods
This is a community-based, cross-sectional study was conducted in North State of Sudan, during the period from March to April 2010.Data was collected as a part of cancer awareness campaign that covered an area inhibited with 40,000 individuals.People were gathered in certain centers (Schools, Clubs Health centres), then were asked to fill the questionnaire about tobacco and alcohol habits and other information regarding their attitudes towards these factors.

Statistical analysis
Statistical analysis was performed by proportion.The Microsoft Excel Office 2007 and the SPSS software (version 16) were used for statistical analysis.

Ethical consent
Written informed consent was obtained from each respondent, ensuring strict anonymity.The Ethical Committee of the Department of Histopathology and Cytology, FMLS, University of Khartoum approved the study.
According to the ethnic groups, the ratios of Northern Arabian groups to Northern Nubian groups and to other scattered tribes were 39:1:5.Although, the ratio of the Northern Nubian groups is very small, but they revealed the highest percentages of tobacco use, followed by Northern Arabian groups, that represent the great majority of the study subjects, as shown in Figure 4.When asking participant about the relation between tobacco use or alcohol consumption and cancer, 96%, 98.2% and 95% agreed that smoking, toombak and alcohol, in this order, can cause cancer.

Discussion
There is a lack of population based data on tobacco and alcohol use in the northern Sudan, it is important to do studies to provide data to improve the local understanding of tobacco and alcohol burden which is a solution to appropriate control strategy.Therefore, the aim of this study was to carry out an epidemiological survey on tobacco and alcohol use in Northern state of Sudan which is strict area inhibited by small population.However, there is only one study on tobacco survey had been performed in Sudan.The study was carried out in 1998 (Idris et al., 1998), and reported that, among children and adolescents (4-17 years) prevalence of tobacco use was quite low (2%, range 1-2%), but there was an abrupt increase up to 25% in late adolescence.Among the adult population aged 18 years and older the prevalences of toombak use (34%) and cigarette smoking (12%) among males were significantly higher than among females (2.5 and 0.9%, respectively).The prevalence of toombak use among the male population aged 18 years and older was significantly higher in the rural than in the urban areas (35% vs 24%), while cigarette smoking had a higher prevalence in urban areas (18% vs 12%).The highest rates of toombak use were found in rural areas among the male population ages 30 years and older (mean 46.6%, range 45-47%).Although, the findings of the current survey showing similar findings regarding the domination of toombak use, but our findings showing higher prevalences both in toombak dipping and tobacco smoking.Due to absence of existing tobacco control policies and activities in Sudan, the prevalence of toombak dipping and smoking is increasing, particularly among the young population, although the current data showing that toombak is more prevalent among adults.However, this might not indicate decreased use among younger population, but may contribute that most of toombak dipper will not quit up death.Moreover, the use of tobacco is increasing among females, though it is considered as social stigma and this disclose why females refused to participate in this survey.
Many factors have contributed to favor smoking initiation among Sudanese population, lack of awareness among the public about the hazards of tobacco use, weak support from the government and strong resistance from the tobacco providers are major reasons for the lack of effective tobacco control efforts that supported by Nongovernmental Organizations.Successful intervention efforts are urgently needed.Commitments from the government are essential in tobacco control.Strict action should be taken on tobacco control issues at different levels including a reduction in tobacco supply, increased tobacco taxation, increased education, tobacco advertising limitations, decreased second-hand smoke exposure and smoking cessation support.The health-care community should also play a leading role in anti-tobacco campaigns and take a more active role in smoking cessation programmes.
In the current study, it was observed that most tobacco users are among less educated people, as well as among labors, although there is a considerable tobacco smoking among engineers.Socioeconomic factors influence  tobacco consumption worldwide (Bobak et al., 2000).
In the developed world, a strong inverse relationship between socioeconomic status and smoking exists such that the poorest and least educated populations are more likely to smoke (Flint and Novotny 1997;Reijneveld 1998;Laaksonen et al., 2005;Wipfli and Samet, 2009).While the few studies characterizing tobacco use in the developing world are unclear, they generally support the findings observed in the developed world (Wipfli and Samet, 2009).Moreover, it has been suggested that tobacco use has become widely prevalent in developing countries and the public health significance of smokingrelated morbidity and mortality will continue to grow (Wipfli and Samet, 2009).
The problem of alcohol consumption in Sudan has widely obscured, since its use is illegal by Sudan Law.However, the number of alcoholic presented in this study might not be the exact number, since most of users refuse to indicate their habits.The presence of a considerable proportion of alcohol-dependents in Northern state of Sudan may subject it to be emphasized for the successful implementation of intervention programmes.The intervention programmes should include preventive strategies and screening programmes to identify different patterns of drinkers and treatment intervention for alcoholdependents.
A limitation of this study is its cross-sectional design.Longitudinal studies of this population in the future might give up insight into developments in the outcomes of existing and future tobacco control measures.Another limitation of this study is that data were obtained via self-report.In the future use of quantitative measures of tobacco exposure such as exhaled carbon monoxide, urine or saliva nicotine would allow a more definitively characterized tobacco exposure in this population.However, self-reported smoking status is the primary measure of smoking status for research and policy, and it provides both a cheaper and widely accepted indicator.