Smoking, Smokeless Tobacco and Alcohol Consumption Among Adults in India: A Sub-National Cross-Sectional Study

Abstract

Background: National estimates of tobacco and alcohol use are insufficient to guide policy at sub-national and district level. This study examines sub-national and district-level prevalence and tobacco and alcohol use and its variations in India. Methods: Data on smoking tobacco, smokeless tobacco (SLT) and alcohol use in adults aged 15-49 was analysed from the National Family Health Survey. Sex-stratified prevalence of each types of tobacco and alcohol use at sub-national administrative units was estimated. We fitted multilevel logistic regressions to quantify the variation at the district and community level in tobacco and alcohol use. Findings: Overall, men used any form of tobacco or alcohol (53%, 52.5–53.4) more than women (7.4%, 95% CI 7.3–7.5). 23.4% (95% CI 23.1-23.9) smoked tobacco, with higher use of any SLT (29%, 28.6-29.4) and alcohol (29.2% 28.7-29.6). Women mostly used SLT (5.6%). Cigarette (13.6%, 13.3–14.0) and bidi (13.2%, 12.9–13.5) were most commonly and almost equally used types of smoking tobacco among men. Gutkha/paan masala with tobacco was the most consumed SLT product among both men (15.3%, 15.0–15.6) and women (2.2%, 2.1–2.3), followed by khaini. Beer was the most commonly used alcohol among men, followed by hard liquor. We found that considerable unexplained variation in tobacco and alcohol use attributed to between-population differences at districts (3.5% in smoking, 4% in alcohol and 6% in SLT) and community level (14.9% in smoking, 19.7% in alcohol and 21.5% in SLT) among males. Among females, between-population differences were even larger at districts (16.6% in smoking, 18% in SLT and 29.9% in alcohol) and community level (35.4% in smoking, 32.8% in SLT and 44% in alcohol). Interpretation: Regular assessment of sub-national tobacco and alcohol consumption across different population groups along with development of local cessation interventions must be integrated with health policy to reduce disease burden and preventable deaths. Funding Statement: No specific funding received for this study Declaration of Interests: All the authors declare that they have no conflict of interest. Ethics Approval Statement: The study was reviewed by the National Institute of Cancer Prevention and Research Institutional Ethics Committee and was exempted from full review as the study was based on an anonymous public use dataset with no identifiable information on the study participants.