Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey

Abstract

Objective: To investigate the demographic, socioeconomic, and geographical distribution of tobacco consumption in India.

Design: Multilevel cross sectional analysis of the 1998-9 Indian national family health survey of 301 984 individuals in 92 447 households in 3215 villages in 440 districts in 26 states.

Setting: Indian states.

Participants: 301 984 adults (> or = 18 years).

Main outcome measures: Dichotomous variable for smoking and chewing tobacco for each respondent (1 if yes, 0 if no) as well as a combined measure of whether an individual smokes, chews tobacco, or both.

Results: Smoking and chewing tobacco are systematically associated with socioeconomic markers at the individual and household level. Individuals with no education are 2.69 times more likely to smoke and chew tobacco than those with postgraduate education. Households belonging to the lowest fifth of a standard of living index were 2.54 times more likely to consume tobacco than those in the highest fifth. Scheduled tribes (odds ratio 1.23, 95% confidence interval 1.18 to 1.29) and scheduled castes (1.19, 1.16 to 1.23) were more likely to consume tobacco than other caste groups. The socioeconomic differences are more marked for smoking than for chewing tobacco. Socioeconomic markers and demographic characteristics of individuals and households do not account fully for the differences at the level of state, district, and village in smoking and chewing tobacco, with state accounting for the bulk of the variation in tobacco consumption.

Conclusion: The distribution of tobacco consumption is likely to maintain, and perhaps increase, the current considerable socioeconomic differentials in health in India. Interventions aimed at influencing change in tobacco consumption should consider the socioeconomic and geographical determinants of people's susceptibility to consume tobacco.

Fig 1

Crude prevalence of adults aged 18 and above who smoke or chew tobacco in 1998-9, by Indian state. The term “crude” means unadjusted prevalence and is computed as number of individuals who smoke and chew tobacco divided by the total number of individuals, in each state, and expressed as percentages

Fig 2

Model based predicted proportion of adults aged 18 and above who smoke or chew tobacco in 1998-9 by Indian state after controlling for demographic and socioeconomic markers at the individual level and for variation in tobacco consumption between households, local areas, and districts. The term “model based” means conditional prevalence and is based on model based, residual, state level differences in smoking and chewing after accounting for between-individual differences in tobacco consumption that are due to age, sex, marital status, caste, religion, education, standard of living, and urban and rural differences, and after taking account of within-state variation attributable to the level of households, local areas, and districts, and expressed as percentages