Extending application of the 'hardcore' definition to smokeless tobacco use: estimates from a nationally representative population in India and its implications

Gendered Pattern and Predictors of Tobacco use in India: Evidence from the Second Round of Global adult Tobacco Survey

Background

India has completed the second round of the Global Adult Tobacco Survey (GATS) to monitor adult tobacco use and progress in tobacco control efforts. This study assesses the gendered pattern of tobacco use and its predictors in the second rounds of GATS.

Material and Methods

Publicly available GATS-2 (2016-2017) data was analyzed which contains self-reported tobacco use information of ≥15 years Indians (n = 74,037). The independent predictors of "smoking only," "smokeless only," and "dual use" among current male and female tobacco users were assessed using the multinomial regression model.

Results

The burden of "smoking only," "smokeless only," and "dual-use" of tobacco were 8.9% (8.74-9.15), 16.69% (16.42-16.96), and 3.89% (3.75-4.03), respectively, in the second round with wide regional variation as well as male dominance in use. Region, age, education, caste, and religion were significantly and consistently associated with different types of tobacco use in both genders. Other contextual predictors of tobacco use were residence, marital status, occupation, awareness, and wealth index (WI).

Conclusions

Tobacco use predictors and their gendered patterns are contextual. Monitoring the predictors for tobacco use, which may change over time, should be given priority in the national tobacco control program.

Hardcore use of smoked and smokeless tobacco products among men and women in Bangladesh: data from two rounds of the global adult tobacco survey

This study examines the prevalence of and factors associated with "hardcore" use of smoked and smokeless tobacco (SLT) products in Bangladesh and the variation in the ages people started using them daily. Data from the 2009 and 2017 rounds of the Global Adult Tobacco Survey for Bangladesh were analyzed using multilevel logistic regression. The prevalence of "hardcore" use of smoked tobacco among current smokers decreased from 15.5% in 2009 to 13.1% in 2017. Almost all hardcore smokers were male in both rounds. Among the current users of SLT, 7.0% were "hardcore" users in 2009, with a higher proportion of females (8.9%) than males (4.8%) and these percentages remained similar in 2017. The current smokers in the age-group 25-64 and the current SLT users in the age-group 45-65+ were more likely than their counterparts to be "hardcore" users. The earlier the participants started using daily, the more likely they were to become "hardcore" users. There was regional variation in the prevalence of "hardcore" use. Coordinated preventive interventions and comprehensive treatment programmes and their equitable geographical distribution are needed.

Tobacco harm reduction: are smokers becoming more hardcore?

We undertook a systematic review to identify and summarise studies on hardcore smoking and hardening to: determine the degree of variability in definitions of hardcore smoking and hardening; assess the evidence for claims that smokers are becoming increasingly hardened within the context of harm reduction as a policy initiative; and identify the determining characteristics of a hardcore smoker. We searched five electronic databases from 1970 to mid-April 2018 using the search term "smok* AND hard* AND (tobacco OR cigar* OR nicotin*)". We included studies if they included a definition of hardcore smokers and/or hardening, and provided a prevalence rate for hard core smokers or empirical evidence for hardening. Definitions of hardcore smoker varied substantially across studies. Hardening was not evident in the general smoking population and we found mounting evidence of softening occurring in smoking populations. These results indicate that hardening of smokers is not occurring and that calls for policy interventions on this basis should be challenged.

Smokeless Tobacco Warnings in Indian Mass Media: Intention and Attempts to Quit

Introduction: In India, over 200 million people use smokeless tobacco (SLT), which increases the risk of cancers. Studies have demonstrated mass media campaigns effectively reduce smoking tobacco prevalence, but few have assessed their impact on SLT cessation. Objectives: This study used data from the Global Adult Tobacco Surveys (GATS) in 2009–2010 and 2016–2017 to examine associations between SLT health warnings in mass media, and intention and attempts to quit using SLT. We also compared the proportion of SLT users who noticed mass media warnings between 2009–2010 and 2016–2017. Materials and Methods: Over 16,000 and 15,000 current SLT users from the GATS-1 and GATS-2, respectively, were used for analysis. Weighted logistic regression models were used to analyze associations between noticed health warnings on SLT packages, newspapers/magazines, television, radio, billboards, cinemas, internet, vehicles, and walls, and intention and attempts to quit SLT. Results: In final models, the odds of intention and attempts to quit were highest among those who noticed warnings in newspapers/magazines (adjusted odds ratio [AOR]: 1.50; 95% confidence interval [CI]: 1.30–1.74) and the internet (AOR: 1.60; 95% CI: 1.12–2.29), respectively. Warnings on SLT packages, television, billboards, radio, vehicles, and walls were also associated with increased cessation behavior. More noticed warnings on SLT packages, television, billboards, and newspapers/magazines in GATS-2 than GATS-1, but fewer heard radio warnings. Conclusions: Among Indian SLT users, we found evidence that SLT warnings in mass media may promote cessation behavior. Health warnings in mass media could play an important role in the overall strategy to reduce the morbidity and mortality associated with SLT use.

Smoking cessation attempts: is it useful to treat hard core smokers?

Background

Hard core smokers have been studied in many countries but only a few trials have compared the effectiveness of smoking cessation with other smokers. The objective of this study was to compare the frequencies of success in smoking cessation between hard-core smokers and other smokers.

Methods

Data were collected in Clermont-Ferrand from the Emile Roux dispensary ‘Pneumology and Tobaccology Centre’ between 1999 and 2009. Assistance with smoking cessation was proposed to 1367 patients but only 1296 patients were included: 219 HCS and 1077 other smokers. Smoking cessation was considered a success when patients were abstinent 6 months after the beginning of cessation. The profiles of the two types of smokers were compared using Chi square test and Student’s t test. Multivariate logistic regression was used to investigate the association between the smoking cessation result and the type of smokers.

Results

HCS more frequently consumed other psychoactive substances (41.1 % vs 25.7 % for other smokers; p < 0.001). Current depression was more frequent in HCS (46.6 % vs 34.8 % for other smokers; p = 0.001). Smoking cessation was less frequent in HCS (45.2 % vs 56.5 % for other smokers ; p = 0.002). In multivariate analysis, after controlling for other factors, the frequency of smoking cessation was not significantly associated with the type of smokers (p = 0.47). After limiting to initial factors (present before the beginning of smoking cessation), the frequency of smoking cessation was still not significantly associated with the type of smokers (p = 0.78).

Conclusion

Smoking cessation is possible for hard core smokers, who should be treated as other types of smokers taking into account other factors:the problem is how to encourage them to try to stop smoking.

Prevalence and risk factors associated with hardcore smoking among rural daily male smokers

BACKGROUND AND OBJECTIVES

The existence of smokers who are resistant to smoking cessation interventions has attracted considerable interest in recent years. Given the paucity of data on that topic in rural China, we aimed to assess the prevalence and risk factors of hardcore smoking in rural China.

METHODS

A cross-sectional study was conducted in 14 villages in Shandong, China. A total of 1,287 male daily smokers were face-to-face interviewed. A multiple logistic regression model was used to explore the associations of demographics, environment, knowledge and attitudes about smoking, and smoking behavior characteristics with hardcore smoking among daily male smokers. A general dominance analysis model was used to access the relative contribution of the determinants that were identified in the multiple logistic regression.

RESULTS

Hardcore smokers constituted 32.9% (n = 423) of daily male smokers. Five determinants for hardcore smoking were identified in the multiple logistic regression. Dominance analysis showed higher level of smoking intensity was the most important determinant of hardcore smoking, followed by being a farmer, starting to smoke daily under the age of 20, younger age, having fewer smokers around.

DISCUSSION AND CONCLUSIONS

This study suggests that hardcore smokers account for a substantial proportion of daily male smokers and are distinct from other groups of daily smokers.

SCIENTIFIC SIGNIFICANCE

Specifically tailored tobacco-control efforts should be made to address the issues incurred by hardcore smokers. (Am J Addict 2016;25:628-633).

Role of tobacco warning labels in informing smokers about risks of smoking among bus drivers in Mangalore, India

BACKGROUND

Smoking tobacco is considered as a leading cause of preventable death, mostly in developing countries like India. One of the primary goals of international tobacco control is to educate smokers about the risks associated with tobacco consumption. Tobacco warning labels (TWLs) on cigarette packages are one of the most common statutory means to communicate health risks of smoking to smokers, with the hope that once educated, they will be more likely to quit the habit.

MATERIALS AND METHODS

The present survey was conducted to assess the effectiveness of TWLs in communicating health risks of tobacco usage among 263 adult smokers working as bus drivers in Karnataka State Road Transport Corporation (KSRTC), Mangalore, India. Information was collected on demographic details, exposure and response to health warnings on tobacco products, intention to quit and nicotine dependency.

RESULTS

The majority (79.5%) of the respondents revealed negative intentions towards quitting smoking. Nearly half of the participants had a 'low' nicotine dependency (47.5%) and 98.1% of the respondents had often noticed warning labels on tobacco packages. These health warnings made 71.5% of the respondents think about quitting smoking. Respondents who noticed advertisement or pictures about dangers of smoking had better knowledge, with respect to lung cancer and impotence as a consequence of tobacco. A higher exposure to warning labels was significantly associated with lower nicotine dependency levels of smokers among the present study population. A significantly higher number of respondents who noticed advertisement or pictures about the dangers of smoking thought about the risks of smoking and were more inclined to think about quitting smoking. As exposure increased, an increase in the knowledge and response of participants was also observed.

CONCLUSIONS

Exposure to tobacco warning labels helps to educate smokers about health risks of tobacco smoking. It may be possible to promote oral health among bus drivers by developing strategies to educate them about these risk factors.

Determinants of tobacco cessation behaviour among smokers and smokeless tobacco users in the states of Gujarat and Andhra Pradesh, India

BACKGROUND

This study was undertaken to identify the socio-demographic determinants of quit attempts among smokers and smokeless tobacco users to identify correlates of tobacco cessation behaviour in India.

MATERIALS AND METHODS

This was a cross-sectional study for the outcome of quit attempts made by current tobacco users in last 12 months in twelve districts in two states. Simple and multivariable logistic regression analysis was used to obtain the odds ratios (ORs) of socio-demographic variables (age, gender, education, occupation, socio- economic status, community, area, type of family) and tobacco user status (smoker/smokeless).

RESULTS

In the combined analysis, a smoker had higher predicted probability of attempting quitting (OR- 1.41,CI 1.14 -1.90), in comparison to a smokeless tobacco user and a tobacco user in the state of Gujarat was less likely to attempt quitting than a user in Andhra Pradesh (OR-0.60, CI 0.47-0.78). The probability of making a quit attempt was higher among tobacco users who were more educated (OR-1.40, CI 1.04-1.94), having a higher socio-economic status (SES) (OR-2.39, CI 1.54-3.69), and belonging to non-agricultural labourer occupational group (OR-1.90, CI 1.29-2.78). The effects were maintained even after adjusting for all other variables. In disaggregated analysis, findings were similar except in smokeless as a separate group, education level was not significantly associated with quit attempts and with lower odds (OR-0.91, CI 0.58-1.42).

CONCLUSIONS

This is one of the first studies to provide useful insight into potential determinants for quit attempts of tobacco users in India including smokeless tobacco users, exploring the socio-demographic patterning of correlates of quit attempts.