Abstract
Introduction:India has experienced marked sociocultural change, economic growth and industry promotion of tobacco products over the past decade. Little is known about the influence of these factors on socioeconomic patterning of tobacco use. This study examines trends in tobacco use by socioeconomic status (SES) in India between 2000 and 2012.Methods:We analyzed data in 2014 from nationally-representative repeated cross-sectional National Sample Surveys (NSS) in India for 1999–2000, 2004–2005 and 2011–2012 (n = 346 612 households). Prevalence and volume trends in cigarette, “bidi” and smokeless tobacco use were examined by household expenditure, educational attainment and caste/tribe status using Two-part model.Results:Prevalence of any tobacco use remained consistent in the poorest households (61.5% to 62.7%) and declined among the richest (43.8% to 36.8%) between 2000–2012. Bidi use declined across all groups (poorest: 26.3% to 16.8%, richest: 19.8% to 10.7%) while cigarette use increased (poorest: 1.2% to 1.3%, richest: 6.5% to 7.0%). Relative to educated and general caste households, between 2000 and 2012 cigarette use in illiterate households increased by 38% and among Scheduled Tribe households increased by 32%. Smokeless tobacco use increased for all households (poorest: 26.2% to 33.9%, richest: 11.4% to 13.5%, Scheduled Tribe: 31.1% to 34.8%, general caste: 13.6% to 18.5%), with greater increases among richer, more educated and general caste households.Conclusion:Marked SES patterning of tobacco use has persisted in India. Improving enforcement of tobacco control policies and monitoring comprehensive smoke-free legislations are needed to address this growing burden.Implications:We found “resilient” tobacco patterns in the last decade despite prevention interventions. SES continues to be inversely associated with tobacco products, with the exception of cigarettes. The declines in bidi use may be getting replaced by increase in cigarette use trends, especially among lower SES groups. The use of smokeless tobacco products has increased across all SES groups and the volume of smokeless tobacco use is not been declining despite a number of policies on tobacco use. This may be attributed to inadequate attention to chewed forms of tobacco in current policies, particularly to implementing pictoral warnings and regulating surrogate advertising. Evaluating the implementation of anti-tobacco policies and ensuring equity dimensions in interventions is urgently needed to address tobacco use inequalities.
Highlights
India has experienced marked sociocultural change, economic growth and industry promotion of tobacco products over the past decade
The declines in bidi use may be getting replaced by increase in cigarette use trends, especially among lower socioeconomic status (SES) groups.The use of smokeless tobacco products has increased across all SES groups and the volume of smokeless tobacco use is not been declining despite a number of policies on tobacco use.This may be attributed to inadequate attention to chewed forms of tobacco in current policies, to implementing pictoral warnings and regulating surrogate advertising
The volume of use decreased 5% faster among Scheduled Caste (SC) households but increased by 9% among Scheduled Tribe (ST) households, relative to the reference base category. These results indicate that bidi use declined among SC and ST households during 2005–2012, but volume of use increased by 8% among ST households in the same period
Summary
India has the second highest number of tobacco users in the world with 229 million users behind China’s 311 million.[1]. Economic growth, rising incomes and urbanization have increased access to tobacco products, for example, cigarettes are becoming more affordable across social strata This may manifest in earlier initiation and access to tobacco products, which could vary by income or education.[6,7,11,12] Second, increases in innovative marketing, packaging and promotion of tobacco products may differentially impact vulnerable populations. Tribal populations may respond to innovative marketing by switching from traditional tobacco products (eg, snuff, hookah, kimam) to mass-market forms of tobacco (eg, bidis and cigarettes).[13,14] in other contexts, nearly half of premature mortality between SES groups has been attributed to tobacco use.[15] In India, where multiple forms of tobacco exist, social patterning of tobacco will be an important driver of inequalities in morbidity and mortality from noncommunicable diseases (NCDs) going forward. Using nationally representative household level data, we examined changing trajectories of socioeconomic patterning in the prevalence and volume of bidi, cigarette and smokeless tobacco use in the country
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