Declining trends in smokeless tobacco use among Indian women: findings from global adult tobacco survey I and II

Trends in smokeless tobacco use and attributable mortality and morbidity in the South-East Asia Region: implications for policy

OBJECTIVES

To describe the prevalence of smokeless tobacco (SLT) use and number of users by year, in addition to trends in mortality and attributable disease burden in countries of the WHO South-East Asia Region (SEAR), to inform policies for SLT control in the Region.

METHODS

For each SEAR country, we obtained data from Global Adult Tobacco Surveys, WHO STEPwise Approach to NCD Risk Factor Surveillance surveys and Demographic and Health Surveys conducted since 2010 to estimate prevalence of SLT use by country, sex and year. Using data from the World Population Prospects database we estimated the number of users by country. Next, using the results of previous meta-analyses and prevalence results, we estimated the population attributable fractions and attributable mortality and morbidity in terms of annual deaths and disability-adjusted life years lost. We then characterised trends in attributable deaths and disease burden for countries with comparable data.

RESULTS

There were wide differences in SLT use prevalence by country. We estimated that, during 2015-2019, there were 165 803 900 SLT users across SEAR, with 479 466 attributable deaths annually of which India accounted for 79.9% with 383 248. Attributable annual deaths increased in some countries during 2015-2019.

CONCLUSIONS

Annual deaths and disease burden attributable to SLT remain high across SEAR and have only declined modestly in recent years. Effective implementation of all WHO Framework Convention on Tobacco Control measures, addressing both supply-side and demand-side issues, in relation to SLT and areca nut products must be prioritised to ensure reductions in mortality and disease burden are sustained and accelerated.

Shifting the gaze on implementation: examining the association between the implementation of tobacco control laws and prevalence of tobacco using data from a nationally representative survey

BACKGROUND

Tobacco use and the associated health burden is a cause of concern in India and globally. Despite several tobacco control policies in place, their sub-optimal and variable implementation across Indian states has remained a concern. Studies evaluating the real-world implementation of policies such as Cigarettes and Other Tobacco Products (COTPA) or National Tobacco Control Program (NTCP) in India and its association with reductions in tobacco use are limited. In this paper, we analyse data from a nationally representative survey to examine how policy implementation is associated with the tobacco use prevalence in India.

METHODS

We analysed data from the Global Adult Tobacco Survey (GATS 2016-17) India using multivariable logistic regression. The dependent variables were the use of smoked tobacco, smokeless tobacco, and tobacco in any form. The independent variables were proxies of implementation of the COTPA and the NTCP. We followed a step-wise backward elimination technique to reach the best fit models.

RESULTS

People exposed to no-smoking signages had lower odds of using tobacco (OR = 0.70, p < 0.001). People exposed to second-hand smoke (OR = 1.51, p < 0.001) and tobacco product advertisements (OR = 1.23, p < 0.001) had greater odds of using tobacco. Exposure to tobacco advertisements was associated with higher odds of using smokeless tobacco (OR = 1.23, p < 0.001), and smoked (OR = 1.33, p < 0.001) forms of tobacco.

CONCLUSION

We find significant association between the implementation of tobacco control laws/programs and tobacco use in India. Our findings highlight the potential that policy implementation holds in reducing population-level tobacco use thus drawing attention towards the implementation phase of policies. The findings have implications on prioritising enforcement of specific tobacco control measures such as smokefree laws, modifying COTPA signages to encompass all tobacco products including against smokeless tobacco use and strengthening indirect advertising restrictions. Future research could focus on developing and validating predictors specific to policy implementation to support policy evaluation efforts.

Chewing tobacco use among pregnant women in India: Analysis of national family health surveys

BACKGROUND

India accounts for over 67% of chewing tobacco users globally and more than 50 million women in India chew tobacco. Chewing tobacco is documented to have negative effects on health of mother and foetus. This research was conducted to study the trends in chewing tobacco use among pregnant women in India, and identify factors associated with chewing tobacco use among pregnant women.

METHODS

We analyzed micro-data from two representative national surveys i.e., National Family Health Survey (NFHS)-4 (2015-16) & NFHS-5 (2019-21). A sample of 32,428 & 28,408 pregnant women were extracted from NFHS-4 & NFHS-5 respectively. Weighted prevalence and 95% confidence levels of chewing tobacco use were computed. State wide comparisons in chewing tobacco use were made. Employing binary logistic regression, adjusted odds ratios (AOR) were computed to identify factors associated with chewing tobacco use.

RESULTS

From NFHS-4 to 5 the prevalence of chewing tobacco use among pregnant women decreased from 4.0%(95% CI = 3.9-4.0) to 2.3%(95% CI = 2.2-2.4) respectively indicating a relative reduction of 42.5%. The highest prevalence remains to be in north-eastern India at 13.0%. Belonging to north-eastern region AOR = 7.0(95 %CI = 6.2-7.9), no-education AOR = 13.2(95 %CI = 10.5-16.5), poorest wealth index AOR = 6.7(95 %CI = 5.6-8.0) and belonging to scheduled tribe AOR = 2.6(95 %CI = 2.4-2.9) was significantly associated with chewing tobacco use among pregnant women.

CONCLUSION

From NFHS-4 to 5, chewing tobacco use during pregnancy has shifted more towards socio-economically vulnerable population. Targeted approaches with accessible and affordable tobacco cessation advice integrated to primary healthcare system are needed.

Smokeless tobacco utilization among tribal communities in India: A population-based cross-sectional analysis of the Global Adult Tobacco Survey, 2016–2017

Introduction

Evidence on smokeless tobacco use is scarce among indigenous communities, with the available literature based either on a specific tribe or on a particular region. Therefore, we aimed to estimate the prevalence of smokeless tobacco and assess its correlation among tribal communities in India.

Methods

We utilized data from the Global Adult Tobacco Survey-2 conducted in 2016–2017. A total of 12,854 tribal people aged &gt;15 years were included in this study. The utilization of smokeless tobacco was estimated using the weighted proportion, and its correlates were assessed by multivariable logistic regression reported as an adjusted odds ratio (AOR) with a 95% confidence interval.

Results

The prevalence of smokeless tobacco use was 32%. Participants aged 31–45 years [AOR: 1.66 (1.37–2.00)], who were men [AOR: 2.37 (1.94–1.90)], and who were daily wage/casual laborers [AOR: 5.32 (3.39–8.34)] were observed to have a significant association with smokeless tobacco. Willingness and attempt to quit smokeless tobacco were higher in Eastern India (31.2%) and central India (33.6%), respectively.

Discussion

We observed one-third of the tribal individuals used smokeless tobacco in India. Tobacco control policies should prioritize men, rural residents, and individuals with fewer years of schooling. Culturally appropriate and linguistically tailored messages are required for behavioral change communication.

Social determinants of tobacco use among tribal communities in India: Evidence from the first wave of Longitudinal Ageing Study in India

BACKGROUND

Evidence on tobacco use among indigenous communities is scarce with available literature based either on a specific region or a particular tribe. Considering the large tribal population in India, it is pertinent to generate evidence on tobacco use among this community. Using nationally representative data, we aimed to estimate the prevalence of tobacco use and assess its determinants and regional variations among older tribal adults in India.

METHODS

We analysed data from Longitudinal Ageing Study in India (LASI), wave-1 conducted in 2017-18. A sample of 11,365 tribal individuals aged ≥ 45 years was included in this study. Descriptive statistics was used to assess the prevalence of smokeless tobacco (SLT), smoking, and any form of tobacco use. Separate multivariable regression models were executed to assess the association of various socio-demographic variables with different forms of tobacco use, reported as adjusted odds ratio (AOR) with 95% confidence interval.

RESULTS

The overall prevalence of tobacco use was around 46%, with 19% of smokers and nearly 32% smokeless tobacco (SLT) users. Participants from the lowest MPCE quintile group had a significantly higher risk of consuming (SLT) [AOR: 1.41 (95% CI: 1.04-1.92)]. Alcohol was found to be associated with both smoking [AOR: 2.09 (95% CI: 1.69-2.58)] and (SLT) [AOR: 3.05 (95% CI: 2.54-3.66)]. Relatively higher odds of consuming (SLT) were associated with the eastern region [AOR: 6.21 (95% CI: 3.91-9.88)].

CONCLUSION

This study highlights the high burden of tobacco use and its social determinants among the tribal population in India, which can help tailor anti-tobacco messages for this vulnerable population to make tobacco control programs more effective.

Marital Disruption and Disparity in Tobacco Use in Reproductive-Aged Women: Evidence from India

Marital disruption defined as widowhood, divorce, or separation, has adverse consequences for women’s health and wellbeing. Extant evidence, however, is primarily available for older women or in developed country settings. Consequences of marital disruption for younger women in the developing countries is relatively less visited. The aim of this cross-sectional study is to assess whether maritally disrupted women of reproductive age (18–49 years) had differential risk of tobacco-use compared to their married counterparts. Using nationally representative data from India, we estimated multivariable logistic regressions to obtain the odds in favor of tobacco-use for maritally disrupted women. We found that compared to women remained in marriage, maritally disrupted women were 1.5 times (95% CI: 1.4–1.6) more likely to consume tobacco. The higher risk of tobacco-use of maritally disrupted women was evident in both younger (age 18–34) and older (age 35–49) cohorts. The results were robust across urban and rural areas, high- and low- education groups, and poor- and non-poor households. The higher odds of tobacco-use among maritally disrupted women persisted even after accounting for household fixed effects. The study findings thus, have implications for strengthening targeted tobacco control policies and health promotion among maritally disrupted women in low-and-middle income countries.

Predictors of smokeless tobacco use among the adult population of north-east India during 2009-2017: A decomposition analysis

Background & objectives

Contrary to overall declining trend in smokeless tobacco (SLT) use in India, an increase is observed in north-east (NE) India. This study examined the predictors of daily SLT use by gender and assessed the demographic and socio-economic characteristics that contribute to gender differences in SLT use in NE India.

Methods

Data collected from 15,259 and 13,574 adults in the two rounds of Global Tobacco Adult Survey 1 and 2 for NE India during 2009-2010 and 2016-2017 were analyzed. Relative change, multivariable binary logistic regression and Blinder-Oaxaca decomposition analysis were used for analysis.

Results

The findings suggest that among women in NE India, the daily SLT use significantly increased by 58 per cent between 2009-2010 to 2016-2017. Women residing in Nagaland, Manipur, Mizoram and Tripura were 3.5 and 2.5 times, respectively more likely to be daily SLT users compared to those in Assam. While age, education and wealth were the significant predictors of SLT use in both women and men, increased odds of SLT use were observed with women's type of occupation and the State of residence. The majority of the gender differences in daily SLT use was explained by differences in work status (44%), age (26%), education (14%) and wealth status (9%) between men and women.

Interpretation & conclusions

Increasing prevalence of SLT use amongst women in the NE States necessitates integration of gender-specific messages on harmful effects of SLT in the ongoing tobacco control programmes and development of culturally appropriate community-based interventions for cessation of SLT use.