Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education

Abstract

Objectives: Smoking of cigarettes or bidis (small, locally manufactured smoked tobacco) in India has likely changed over the last decade. We sought to document trends in smoking prevalence among Indians aged 15-69 years between 1998 and 2015.

Design: Comparison of 3 nationally representative surveys representing 99% of India's population; the Special Fertility and Mortality Survey (1998), the Sample Registration System Baseline Survey (2004) and the Global Adult Tobacco Survey (2010).

Setting: India.

Participants: About 14 million residents from 2.5 million homes, representative of India.

Main outcome measures: Age-standardised smoking prevalence and projected absolute numbers of smokers in 2015. Trends were stratified by type of tobacco smoked, age, gender and education level.

Findings: The age-standardised prevalence of any smoking in men at ages 15-69 years fell from about 27% in 1998 to 24% in 2010, but rose at ages 15-29 years. During this period, cigarette smoking in men became about twofold more prevalent at ages 15-69 years and fourfold more prevalent at ages 15-29 years. By contrast, bidi smoking among men at ages 15-69 years fell modestly. The age-standardised prevalence of any smoking in women at these ages was 2.7% in 2010. The smoking prevalence in women born after 1960 was about half of the prevalence in women born before 1950. By contrast, the intergenerational changes in smoking prevalence in men were much smaller. The absolute numbers of men smoking any type of tobacco at ages 15-69 years rose by about 29 million or 36% in relative terms from 79 million in 1998 to 108 million in 2015. This represents an average increase of about 1.7 million male smokers every year. By 2015, there were roughly equal numbers of men smoking cigarettes or bidis. About 11 million women aged 15-69 smoked in 2015. Among illiterate men, the prevalence of smoking rose (most sharply for cigarettes) but fell modestly among men with grade 10 or more education. The ex-smoking prevalence in men at ages 45-59 years rose modestly but was low: only 5% nationally with about 4 current smokers for every former smoker.

Conclusions: Despite modest decreases in smoking prevalence, the absolute numbers of male smokers aged 15-69 years has increased substantially over the last 15 years. Cigarettes are displacing bidi smoking, most notably among young adult men and illiterate men. Tobacco control policies need to adapt to these changes, most notably with higher taxation on tobacco products, so as to raise the currently low levels of adult smoking cessation.

Figure 1

Smoking prevalence by age and gender (with 99% CI): 1998–2010. GATS, Global Adult Tobacco Survey; SFMS, Special Fertility and Mortality Survey.

Figure 2

Age-standardised smoking prevalence among adults aged 15-69 years, by state: 1998–2010, absolute change (%) per decade and number of smokers in 2015 (in millions). GATS, Global Adult Tobacco Survey; SFMS, Special Fertility and Mortality Survey. Note that reliable estimates for absolute changes per decade could not be estimated for women. We applied GATS 2010 smoking prevalence for women ages 15-69 years to the 2015 population.

Figure 3

Smoking prevalence by decade of birth cohort and gender: 1998–2010. Note: Numbers near each point represent the sample size. GATS, Global Adult Tobacco Survey; SFMS, Special Fertility and Mortality Survey.

Figure 4

Age-standardised rate (ASR) of smoking among men by age group, product between 1998 to 2010 and number of smokers in 2015 (in millions). ASRR, age-standardised rate ratios between the Global Adult Tobacco Survey and the Special Fertility and Mortality Survey.

Figure 5

Age-standardised rate (ASR) of smoking among men aged 15 to 69 years by product, and by two levels of education: 1998–2010. ASRR, age-standardised rate ratios between the Global Adult Tobacco Survey and the Special Fertility and Mortality Survey.

Figure 6

Ex-smoker rates in India among men (45–59 years) from 2004 to 2010; absolute number (in million) of smokers and ex-smokers in 2015. GATS, Global Adult Tobacco Survey; UN, United Nations. Note that, * it is unlikely that smoking cessation has decreased from 2010-2015. Therefore we assigned GATS 2010 ex-smoking prevalence to Assam, West Bengal and Punjab which reported a decline. Odisha was excluded from the analyses due to few numbers of smokes in the GATS. †We applied GATS 2010 smoking and ex-smoking prevalence for women to estimate 2015 absolute totals. ‡The number of smokers and ex-smokers are based on 2015 UN Population totals for India.