Pattern of Smoking and Alcohol Consumption among Adult Population of District Shimla: A Descriptive Cross-Sectional Study

doi:10.47310/hjamsr.2021.v02i02.061

Abstract

Background: Abuse of legal substances in India includes alcohol and tobacco, which are the major risk factors for various non-communicable diseases and deaths. This study was done to evaluate the pattern of Smoking and Alcohol consumption among adult population of District Shimla. Methods: A descriptive cross sectional survey was conducted amongst the participants in the age group of 18 to 60 years, using google forms. The questionnaire was circulated among residents of district Shimla for responses. Results: A total of 400 respondents including 194(48.5%) females and 206(51.5%) males from district Shimla were participated in the study. Among the participants of the majority 189(47.3%) were in age group of 31-40 years, 159(39.8%) were in Govt Job, 338(84.5%) were graduate & above, 235(58.8%) were from urban area and 387(96.8%) were belong to Hindu Religion. Among the total 400 study participants, majority 45 (11.3%) were smokers. Majority of them (26) smoke daily. Most of the them (23) smoke 2 cigarettes daily on an average. Among the 194 females in the study, 3(1.5%) were smokers while among 206 males 42(20.4%) were smokers. So males were significantly more smoker statistically. Among the total 400 study participants, majority 81 (20.3%) were alcoholic. Majority of them (46) took alcohol once weekly. Most of the them (31) took 3 pegs of alcohol on an average in one time. Among the 194 females in the study, 5(2.6%) were alcoholic while among 206 males 76(36.9%) were alcoholic. So males were significantly more alcoholic statistically. Conclusion: To prevent the burden from legal substances like tobacco & alcohol abuse, a cost-effective non-pharmacological approach is required.

Keywords

Pattern of Smoking and Alcohol consumption

Adult population

Shimla.

Important Note:

Key findings:

Key findings reveal a high prevalence of smoking and alcohol consumption among the adult population in District Shimla, with males significantly more affected than females. Daily smoking and weekly alcohol intake were common, with males showing significantly higher rates of both behaviors. The study underscores the need for effective preventive measures against substance abuse.

What is known and what is new?

The abstract highlights the prevalence of smoking and alcohol consumption among adults in District Shimla, India, shedding light on the significant gender disparities. Males exhibited higher rates of both behaviors compared to females. The study underscores the urgent need for non-pharmacological interventions to mitigate the adverse effects of substance abuse in the region.

What is the implication, and what should change now?

The study underscores the urgent need for interventions to address the high prevalence of smoking and alcohol consumption, particularly among males, in District Shimla. Implementing effective non-pharmacological strategies tailored to the local context is crucial to mitigate the burden of substance abuse and prevent associated non-communicable diseases and deaths.

INTRODUCTION:

Substance abuse in various forms has always been culturally and socially acceptable particularly among adults in Himachal Pradesh. Angoori (a local grape wine from Kinnaur region), moori (local apple wine from upper region of Shimla Kullu Kinnaur), Aara (famous local drink from Lahaul and spiti), Chhang and lugdi are some of the different forms of alcohol beverages that are freely brewed, distributed and consumed at home without any restriction. Tobacco use in different forms (bidi, hookah, chilam) has been used for ages by the people of Himachal. [1]

Tobacco smoking is the biggest public health threat of the current era. Worldwide, smoking-related diseases kill an estimated 4 million people every year. This number is predicted to rise to a staggering 10 million a year over the next two decades. There is an overwhelming body of evidence of Tobacco smoking is the biggest public health threat of the current era. Worldwide, smoking-related diseases kill an estimated 4 million people every year. This number is predicted to rise to a staggering 10 million a year over the next two decades. There is an overwhelming body of evidence of increased cancer risk in cigarette smokers. [2]

According to the WHO, there are three million deaths yearly annually due to alcohol consumption, which constitutes around 5.3% of total deaths globally and 5.1% of the global burden of disability-adjusted life years (DALYs) due to alcohol consumption. The consumption of alcohol leads to various digestive or cardiovascular diseases, including cancer. [3]

Legislative efforts to control substance abuse don’t look very promising either, as we can see people smoking publically, wine shops selling alcohol to minors, smokeless tobacco products being sold even after prohibition. Most of the bars in Shimla city allow minors to drink and smoke keeping their monetary benefits above the law. [4,5]

Though not much scientific data on this problem is available, some studies have reported high levels of alcohol and tobacco use among adolescents and youth in Shimla City. [2,6,7]

A number of studies have been done in different parts of India to see the pattern of Smoking and Alcohol consumption; such studies are limited in hilly areas of District Shimla. Thus the present study was developed to evaluate the pattern of Smoking and Alcohol consumption among the adult population of District Shimla.

OBJECTIVES OF THE STUDY:

To evaluate the pattern of Smoking and Alcohol consumption among adult population of District Shimla.

RESEARCH METHODOLOGY:

Research Approach -Descriptive
Research Design- Cross-sectional survey design
Study area: District Shimla
Study duration- between September 2021- October 2021
Study population- Adults population aged between 18-60 years
Sample size- 400 adults assuming 50% adults have adequate knowledge regarding Smoking and Alcohol consumption, 5% absolute error, 95% confidence level, and 5% non-response rate.
Study tool: A google form questionnaire consisting of questions regarding socio-demography and pattern of Smoking and Alcohol consumption was created.
Inclusive Criteria- who were willing to participate in the study.
Exclusion Criteria: who were not willing to participate in the study
Validity of tool - by the experts in this field
Data collection- Data was collected under the guidance of supervisors. The google form questionnaire was circulated via online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin. Responses were then recorded in a Google Excel spreadsheet, the information from which was used to generate graphical display.
Data analysis- Data was collected and entered in Microsoft excel spreadsheet, cleaned for errors and analysed with Epi Info V7 Software with appropriate statistical test in terms of frequencies, percentage, mean standard deviation etc..
Ethical Considerations- Participants confidentiality and anonymity was maintained.

RESULTS:

Present study was developed to evaluate the pattern of Smoking and Alcohol consumption among the adult population of District Shimla. A total of 400 respondents including 194(48.5%) females and 206(51.5%) males from district Shimla participated in the study. Among the participants of the majority 189(47.3%) were in age group of 31-40 years, 159(39.8%) were in Govt Job, 338(84.5%) were graduate & above, 235(58.8%) were from urban area and 387(96.8%) were belong to Hindu Religion. (Table-1)

Table-1: Socio-Demographic Characteristics of Study Participants

		Frequency	Percent
Age Groups	18-30	108	27.0
	31-40	189	47.3
	41-50	73	18.3
	51-60	30	7.5
Gender	Female	194	48.5
Gender	Male	206	51.5
Occupation	Farmer	33	8.3
	Govt. Job	159	39.8
	Pvt. Job	88	22.0
	Unemployed	120	30.0
Education	Illiterate	5	1.3
	Up to Middle Class	1	.3
	10^th & 12^th	56	14.0
	Graduate & Above	338	84.5
Area	Rural	165	41.3
Area	Urban	235	58.8
Religion	Hindu	387	96.8
	Muslim	2	.5
	Christian	2	.5
	Others	9	2.3
Total		400	100

Among the total 400 study participants, the majority 45 (11.3%) were smokers. Majority of them (26) smoke daily. Most of them (23) smoke 2 cigarettes daily on an average. (Table-2)

Table-2: Pattern of Smoking among Study Participants

		Frequency	Percent
Do you smoke?	No	355	88.8
Do you smoke?	Yes	45	11.3
If yes , how many days in a week do you smoke?	0	355	88.8
	1	3	.8
	2	2	.5
	3	4	1.0
	4	4	1.0
	5	2	.5
	6	4	1.0
	7	26	6.5
If yes, How many cigarettes do you smoke in a day?	0	355	88.8
	1	5	1.3
	2	23	5.8
	3	5	1.3
	5	7	1.8
	7	2	.5
	≥10	3	.8
	Total	400	100.0

Among the 194 females in the study, 3(1.5%) were smokers while among 206 males 42(20.4%) were smokers. So males were significantly more smoker statistically. (Table-3)

Table-3: Pattern of Smoking According to Gender

			Smokers		Total	P value
			No	Yes	Total	P value
Gender	Female	Count	191	3	194	0.000
	Female	%	98.5%	1.5%	100.0%
	Male	Count	164	42	206
	Male	%	79.6%	20.4%	100.0%
Total		Count	355	45	400
Total		%	88.8%	11.2%	100.0%

Among the total 400 study participants, the majority 81 (20.3%) were alcoholic. Majority of them (46) took alcohol once a week. Most of them (31) took 3 pegs of alcohol on average at one time. (Table-4)

Table-4: Pattern of Alcohol among Study Participants

		Frequency	Percent
Are you an alcoholic?	No	319	79.8
	Yes	81	20.3
	Total	400	100.0
If yes, how many days in a week do you take alcohol ?	0	321	80.3
	1	46	11.5
	2	18	4.5
	3	6	1.5
	4	2	.5
	5	1	.3
	7	6	1.5
How much alcohol do you take in at one time?	0	323	80.8
	1	7	1.8
	2	17	4.3
	3	31	7.8
	4	13	3.3
	5	3	.8
	6	4	1.0
	8	2	.5
	Total	400	100.0

Among the 194 females in the study, 5(2.6%) were alcoholic while among 206 males 76(36.9%) were alcoholic. So males were significantly more alcoholic statistically. (Table-5)

Table-5: Pattern of Smoking According to Gender

			Alcoholic		Total	P value
			No	yes	Total	P value
Gender	Female	Count	189	5	194	0.000
	Female	%	97.4%	2.6%	100.0%
	Male	Count	130	76	206
	Male	%	63.1%	36.9%	100.0%
Total		Count	319	81	400
Total		%	79.8%	20.2%	100.0%

DISCUSSION:

In the present study, among the total 400 study participants, the majority 45 (11.3%) were smokers. Majority of them (26) smoke daily. Most of them (23) smoke 2 cigarettes daily on an average. Among the 194 females in the study, 3(1.5%) were smokers while among 206 males 42(20.4%) were smokers. So males were significantly more smoker statistically. In the NFHS-5 Survey in 2019-20 in District Shimla 1.5% of females and 31.7% females were using any kind of tobacco. [8]

In the current study, among the total 400 study participants, the majority 81 (20.3%) were alcoholic. Majority of them (46) took alcohol once a week. Most of them (31) took 3 pegs of alcohol on average at one time. Among the 194 females in the study, 5(2.6%) were alcoholic while among 206 males 76(36.9%) were alcoholic. So males were significantly more alcoholic statistically. In the NFHS-5 Survey in 2019-20 in District Shimla 0.5% of females and 34.4% females were consuming alcohol. [8]

Table-6: Pattern of Smoking & Alcohol in District Shimla as Per NFHS-5

Women age 15 years and above who use any kind of tobacco (%)	1.5 %
Men age 15 years and above who use any kind of tobacco (%)	31.7 %
Women age 15 years and above who consume alcohol (%)	0.5 %
Men age 15 years and above who consume alcohol (%)	34.4%

CONCLUSION:

As smoking & alcohol are individual behaviors influenced by individual and societal influences, efforts to foster positive long-term interventions focused at the individual, family, and community levels should be the focus of the program and policy makers in India as well in Himachal Pradesh. To prevent the disease burden from legal substances abuse like alcohol & smoking, a cost-effective non-pharmacological approach is required. We recommend the detailed study to understand the current scenario of substance abuse in Shimla city and to develop a comprehensive program to combat the problem.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College,Shimla.

REFERENCES:

Kumar, D., A. Parashar, and A. Thakur. "Alcohol and other substance abuse among youth: an obvious but neglected scenario in Shimla city of Himachal Pradesh, India." International Journal of Community Medicine and Public Health 3.8 (2016): 2355-2356. https://www.researchgate.net/profile/Devender-Kumar-6/publication/305715806_Alcohol_and_other_substance_abuse_among_youth_an_obvious_but_neglected_scenario_in_Shimla_city_of_Himachal_Pradesh_India/links/5cac26ef299bf118c4bd0928/Alcohol-and-other-substance-abuse-among-youth-an-obvious-but-neglected-scenario-in-Shimla-city-of-Himachal-Pradesh-India.pdf
Thakur, Durgesh, et al. "Prevalence of cigarette smoking and its predictors among school going adolescents of North India." South Asian journal of cancer 3.04 (2014): 193-195. https://www.thieme-connect.com/products/ejournals/abstract/10.4103/2278-330X.142946
Sivapuram, Madhava Sai, et al. "Prevalence of alcohol and tobacco use in india and implications for COVID-19-Niyantrita Madhumeha Bharata study projections." Journal of Medicine and Life 13.4 (2020): 499. https://doi.org/10.25122%2Fjml-2020-0079
Himachal watcher. Shimla Police tightens grip on drug peddlers, dealers, suppliers. Available at: https://himachalwatcher.com/2016/02/04/shimlapolice-tightens-grip-on-drug-peddlers-dealerssuppliers/.(Accessed on 24/10/2021.)
The Times of India. Courier firm owner held in drug racket. Available at http://timesofindia.indiatimes.com/city/delhi/Courier-firm-owner-held-in-drugracket/ articleshowm/51665698.cms. (Accessed on 25/10/2021)
Sharma, Parul, and Anita Thakur. "Pattern of substance abuse in patients attending psychiatry OPD of IGMC, Shimla." IOSR Journal of Dental and Medical Sciences 13.8 (2014): 853-61.
Kumar, Devender, Anupam Parashar, and Anita Thakur. "Tobacco use and its correlates among youth in a Northern Urban City of India." Int J Sci Res 5.2 (2016): 1577-82. https://www.researchgate.net/profile/Devender-Kumar-6/publication/332092653_Tobacco_Use_and_its_Correlates_among_Youth_in_a_Northern_Urban_City_of_India/links/5cac2711299bf118c4bd0944/Tobacco-Use-and-its-Correlates-among-Youth-in-a-Northern-Urban-City-of-India.pdf
NFHS-5 Shimla. Available at: http://rchiips.org/nfhs/NFHS-5_FCTS/FactSheet_HP.pdf (Accessed on 27/10/2021)

Important Note:

Key findings:

Key findings reveal a high prevalence of smoking and alcohol consumption among the adult population in District Shimla, with males significantly more affected than females. Daily smoking and weekly alcohol intake were common, with males showing significantly higher rates of both behaviors. The study underscores the need for effective preventive measures against substance abuse.

What is known and what is new?

The abstract highlights the prevalence of smoking and alcohol consumption among adults in District Shimla, India, shedding light on the significant gender disparities. Males exhibited higher rates of both behaviors compared to females. The study underscores the urgent need for non-pharmacological interventions to mitigate the adverse effects of substance abuse in the region.

What is the implication, and what should change now?

The study underscores the urgent need for interventions to address the high prevalence of smoking and alcohol consumption, particularly among males, in District Shimla. Implementing effective non-pharmacological strategies tailored to the local context is crucial to mitigate the burden of substance abuse and prevent associated non-communicable diseases and deaths.

INTRODUCTION:

Substance abuse in various forms has always been culturally and socially acceptable particularly among adults in Himachal Pradesh. Angoori (a local grape wine from Kinnaur region), moori (local apple wine from upper region of Shimla Kullu Kinnaur), Aara (famous local drink from Lahaul and spiti), Chhang and lugdi are some of the different forms of alcohol beverages that are freely brewed, distributed and consumed at home without any restriction. Tobacco use in different forms (bidi, hookah, chilam) has been used for ages by the people of Himachal. [1]

Tobacco smoking is the biggest public health threat of the current era. Worldwide, smoking-related diseases kill an estimated 4 million people every year. This number is predicted to rise to a staggering 10 million a year over the next two decades. There is an overwhelming body of evidence of Tobacco smoking is the biggest public health threat of the current era. Worldwide, smoking-related diseases kill an estimated 4 million people every year. This number is predicted to rise to a staggering 10 million a year over the next two decades. There is an overwhelming body of evidence of increased cancer risk in cigarette smokers. [2]

According to the WHO, there are three million deaths yearly annually due to alcohol consumption, which constitutes around 5.3% of total deaths globally and 5.1% of the global burden of disability-adjusted life years (DALYs) due to alcohol consumption. The consumption of alcohol leads to various digestive or cardiovascular diseases, including cancer. [3]

Legislative efforts to control substance abuse don’t look very promising either, as we can see people smoking publically, wine shops selling alcohol to minors, smokeless tobacco products being sold even after prohibition. Most of the bars in Shimla city allow minors to drink and smoke keeping their monetary benefits above the law. [4,5]

Though not much scientific data on this problem is available, some studies have reported high levels of alcohol and tobacco use among adolescents and youth in Shimla City. [2,6,7]

A number of studies have been done in different parts of India to see the pattern of Smoking and Alcohol consumption; such studies are limited in hilly areas of District Shimla. Thus the present study was developed to evaluate the pattern of Smoking and Alcohol consumption among the adult population of District Shimla.

OBJECTIVES OF THE STUDY:

To evaluate the pattern of Smoking and Alcohol consumption among adult population of District Shimla.

RESEARCH METHODOLOGY:

Research Approach -Descriptive
Research Design- Cross-sectional survey design
Study area: District Shimla
Study duration- between September 2021- October 2021
Study population- Adults population aged between 18-60 years
Sample size- 400 adults assuming 50% adults have adequate knowledge regarding Smoking and Alcohol consumption, 5% absolute error, 95% confidence level, and 5% non-response rate.
Study tool: A google form questionnaire consisting of questions regarding socio-demography and pattern of Smoking and Alcohol consumption was created.
Inclusive Criteria- who were willing to participate in the study.
Exclusion Criteria: who were not willing to participate in the study
Validity of tool - by the experts in this field
Data collection- Data was collected under the guidance of supervisors. The google form questionnaire was circulated via online modes like e-mail and social media platforms like Whatsapp groups, Facebook, Instagram and Linkedin. Responses were then recorded in a Google Excel spreadsheet, the information from which was used to generate graphical display.
Data analysis- Data was collected and entered in Microsoft excel spreadsheet, cleaned for errors and analysed with Epi Info V7 Software with appropriate statistical test in terms of frequencies, percentage, mean standard deviation etc..
Ethical Considerations- Participants confidentiality and anonymity was maintained.

RESULTS:

Present study was developed to evaluate the pattern of Smoking and Alcohol consumption among the adult population of District Shimla. A total of 400 respondents including 194(48.5%) females and 206(51.5%) males from district Shimla participated in the study. Among the participants of the majority 189(47.3%) were in age group of 31-40 years, 159(39.8%) were in Govt Job, 338(84.5%) were graduate & above, 235(58.8%) were from urban area and 387(96.8%) were belong to Hindu Religion. (Table-1)

Table-1: Socio-Demographic Characteristics of Study Participants

		Frequency	Percent
Age Groups	18-30	108	27.0
	31-40	189	47.3
	41-50	73	18.3
	51-60	30	7.5
Gender	Female	194	48.5
Gender	Male	206	51.5
Occupation	Farmer	33	8.3
	Govt. Job	159	39.8
	Pvt. Job	88	22.0
	Unemployed	120	30.0
Education	Illiterate	5	1.3
	Up to Middle Class	1	.3
	10^th & 12^th	56	14.0
	Graduate & Above	338	84.5
Area	Rural	165	41.3
Area	Urban	235	58.8
Religion	Hindu	387	96.8
	Muslim	2	.5
	Christian	2	.5
	Others	9	2.3
Total		400	100

Among the total 400 study participants, the majority 45 (11.3%) were smokers. Majority of them (26) smoke daily. Most of them (23) smoke 2 cigarettes daily on an average. (Table-2)

Table-2: Pattern of Smoking among Study Participants

		Frequency	Percent
Do you smoke?	No	355	88.8
Do you smoke?	Yes	45	11.3
If yes , how many days in a week do you smoke?	0	355	88.8
	1	3	.8
	2	2	.5
	3	4	1.0
	4	4	1.0
	5	2	.5
	6	4	1.0
	7	26	6.5
If yes, How many cigarettes do you smoke in a day?	0	355	88.8
	1	5	1.3
	2	23	5.8
	3	5	1.3
	5	7	1.8
	7	2	.5
	≥10	3	.8
	Total	400	100.0

Among the 194 females in the study, 3(1.5%) were smokers while among 206 males 42(20.4%) were smokers. So males were significantly more smoker statistically. (Table-3)

Table-3: Pattern of Smoking According to Gender

			Smokers		Total	P value
			No	Yes	Total	P value
Gender	Female	Count	191	3	194	0.000
	Female	%	98.5%	1.5%	100.0%
	Male	Count	164	42	206
	Male	%	79.6%	20.4%	100.0%
Total		Count	355	45	400
Total		%	88.8%	11.2%	100.0%

Among the total 400 study participants, the majority 81 (20.3%) were alcoholic. Majority of them (46) took alcohol once a week. Most of them (31) took 3 pegs of alcohol on average at one time. (Table-4)

Table-4: Pattern of Alcohol among Study Participants

		Frequency	Percent
Are you an alcoholic?	No	319	79.8
	Yes	81	20.3
	Total	400	100.0
If yes, how many days in a week do you take alcohol ?	0	321	80.3
	1	46	11.5
	2	18	4.5
	3	6	1.5
	4	2	.5
	5	1	.3
	7	6	1.5
How much alcohol do you take in at one time?	0	323	80.8
	1	7	1.8
	2	17	4.3
	3	31	7.8
	4	13	3.3
	5	3	.8
	6	4	1.0
	8	2	.5
	Total	400	100.0

Among the 194 females in the study, 5(2.6%) were alcoholic while among 206 males 76(36.9%) were alcoholic. So males were significantly more alcoholic statistically. (Table-5)

Table-5: Pattern of Smoking According to Gender

			Alcoholic		Total	P value
			No	yes	Total	P value
Gender	Female	Count	189	5	194	0.000
	Female	%	97.4%	2.6%	100.0%
	Male	Count	130	76	206
	Male	%	63.1%	36.9%	100.0%
Total		Count	319	81	400
Total		%	79.8%	20.2%	100.0%

DISCUSSION:

In the present study, among the total 400 study participants, the majority 45 (11.3%) were smokers. Majority of them (26) smoke daily. Most of them (23) smoke 2 cigarettes daily on an average. Among the 194 females in the study, 3(1.5%) were smokers while among 206 males 42(20.4%) were smokers. So males were significantly more smoker statistically. In the NFHS-5 Survey in 2019-20 in District Shimla 1.5% of females and 31.7% females were using any kind of tobacco. [8]

In the current study, among the total 400 study participants, the majority 81 (20.3%) were alcoholic. Majority of them (46) took alcohol once a week. Most of them (31) took 3 pegs of alcohol on average at one time. Among the 194 females in the study, 5(2.6%) were alcoholic while among 206 males 76(36.9%) were alcoholic. So males were significantly more alcoholic statistically. In the NFHS-5 Survey in 2019-20 in District Shimla 0.5% of females and 34.4% females were consuming alcohol. [8]

Table-6: Pattern of Smoking & Alcohol in District Shimla as Per NFHS-5

Women age 15 years and above who use any kind of tobacco (%)	1.5 %
Men age 15 years and above who use any kind of tobacco (%)	31.7 %
Women age 15 years and above who consume alcohol (%)	0.5 %
Men age 15 years and above who consume alcohol (%)	34.4%

CONCLUSION:

As smoking & alcohol are individual behaviors influenced by individual and societal influences, efforts to foster positive long-term interventions focused at the individual, family, and community levels should be the focus of the program and policy makers in India as well in Himachal Pradesh. To prevent the disease burden from legal substances abuse like alcohol & smoking, a cost-effective non-pharmacological approach is required. We recommend the detailed study to understand the current scenario of substance abuse in Shimla city and to develop a comprehensive program to combat the problem.

Funding: No funding sources.

Conflict of interest: None declared.

Ethical approval: The study was approved by the Institutional Ethics Committee of Indira Gandhi Medical College, Shimla.

REFERENCES:

Kumar, D., A. Parashar, and A. Thakur. "Alcohol and other substance abuse among youth: an obvious but neglected scenario in Shimla city of Himachal Pradesh, India." International Journal of Community Medicine and Public Health 3.8 (2016): 2355-2356. https://www.researchgate.net/profile/Devender-Kumar-6/publication/305715806_Alcohol_and_other_substance_abuse_among_youth_an_obvious_but_neglected_scenario_in_Shimla_city_of_Himachal_Pradesh_India/links/5cac26ef299bf118c4bd0928/Alcohol-and-other-substance-abuse-among-youth-an-obvious-but-neglected-scenario-in-Shimla-city-of-Himachal-Pradesh-India.pdf
Thakur, Durgesh, et al. "Prevalence of cigarette smoking and its predictors among school going adolescents of North India." South Asian journal of cancer 3.04 (2014): 193-195. https://www.thieme-connect.com/products/ejournals/abstract/10.4103/2278-330X.142946
Sivapuram, Madhava Sai, et al. "Prevalence of alcohol and tobacco use in india and implications for COVID-19-Niyantrita Madhumeha Bharata study projections." Journal of Medicine and Life 13.4 (2020): 499. https://doi.org/10.25122%2Fjml-2020-0079
Himachal watcher. Shimla Police tightens grip on drug peddlers, dealers, suppliers. Available at: https://himachalwatcher.com/2016/02/04/shimlapolice-tightens-grip-on-drug-peddlers-dealerssuppliers/.(Accessed on 24/10/2021.)
The Times of India. Courier firm owner held in drug racket. Available at http://timesofindia.indiatimes.com/city/delhi/Courier-firm-owner-held-in-drugracket/ articleshowm/51665698.cms. (Accessed on 25/10/2021)
Sharma, Parul, and Anita Thakur. "Pattern of substance abuse in patients attending psychiatry OPD of IGMC, Shimla." IOSR Journal of Dental and Medical Sciences 13.8 (2014): 853-61.
Kumar, Devender, Anupam Parashar, and Anita Thakur. "Tobacco use and its correlates among youth in a Northern Urban City of India." Int J Sci Res 5.2 (2016): 1577-82. https://www.researchgate.net/profile/Devender-Kumar-6/publication/332092653_Tobacco_Use_and_its_Correlates_among_Youth_in_a_Northern_Urban_City_of_India/links/5cac2711299bf118c4bd0944/Tobacco-Use-and-its-Correlates-among-Youth-in-a-Northern-Urban-City-of-India.pdf
NFHS-5 Shimla. Available at: http://rchiips.org/nfhs/NFHS-5_FCTS/FactSheet_HP.pdf (Accessed on 27/10/2021)

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