Background: In India most adult deaths involve vascular disease, pulmonary tuberculosis, or other respiratory disease, and men have smoked cigarettes or bidis (which resemble small cigarettes) for several decades. The study objective was to assess age-specific mortality from smoking among men (since few women smoke) in urban and in rural India.
Methods: We did a case-control study of the smoking habits of 27000 urban and 16000 rural men who had died in the state of Tamil Nadu, southern India, from medical causes (ie, any cause other than accident, homicide, or suicide), and of 20000 urban and 15000 rural male controls. The main analyses are of mortality at ages 25-69 years.
Indian Girl Smoking
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Findings: In the urban study area, the death rates from medical causes of ever smokers were double those of never smokers (standardised risk ratio at ages 25-69 years 2.1 [95% CI 2.0-2.2]). The risks were substantial both for cigarette smoking (the main urban habit) and for bidi smoking. Of this excess mortality among smokers, a third involved respiratory disease, chiefly tuberculosis (4.5 [4.0-5.0], smoking-attributed fraction 61%), a third involved vascular disease (1.8 [1.7-1.9], smoking-attributed fraction 24%), 11% involved cancer (2.1 [1.9-2.4], smoking-attributed fraction 32%), chiefly of the respiratory or upper digestive tracts, and 14% involved alcoholism or cirrhosis (3.3 [2.9-3.8], not attributed to smoking). Among ever smokers, the absolute excess mortality from tuberculosis was substantial throughout the age range 25-69 years. (A separate survey of 250000 men living in the urban study area found that ever smokers are three times as likely as never smokers to report a history of tuberculosis, corresponding to a higher rate of progression of chronic subclinical infection to clinical disease.) The proportional excesses of respiratory, vascular, and neoplastic mortality at ages 25-69 years among ever smokers in the urban study area were replicated, each with similarly narrow CI for the risk ratio, in the rural study area (where bidi smoking predominated), and are taken to be largely or wholly causal. For urban and for rural death from medical causes at older ages (> or =70 years), the standardised risk ratio was 1.3.
Interpretation: Smoking, which increases the incidence of clinical tuberculosis, is a cause of half the male tuberculosis deaths in India, and of a quarter of all male deaths in middle age (plus smaller fractions of the deaths at other ages). At current death rates, about a quarter of cigarette or bidi smokers would be killed by tobacco at ages 25-69 years, those killed at these ages losing about 20 years of life expectancy. Overall, smoking currently causes about 700000 deaths per year in India, chiefly from respiratory or vascular disease: about 550000 men aged 25-69 years, about 110000 older men, and much smaller numbers of women (since few women smoke).
In South and Southeast Asian countries, tobacco is consumed in diverse forms, and smoking among women is very low. We aimed to provide national estimates of prevalence and social determinants of smoking and smokeless tobacco use among men and women separately.
Prevalence and type of tobacco use among men and women varied across the countries and among socio-economic sub groups. Smoking prevalence was much lower in women than men in all countries. Smoking among men was very high in Indonesia, Maldives, and Bangladesh. Smokeless tobacco (mainly chewable) was used in diverse forms, particularly in India, among both men and women. Chewing tobacco was common in Nepal, Bangladesh, Maldives, and Cambodia. Both smoking and smokeless tobacco use were associated with higher age, lower education, and poverty, but their association with place of residence and marital status was not uniform between men and women across the countries.
The Southeast Asia region is home to nearly 400 million tobacco users, who experience about 1.2 million deaths annually [7]. Although smokeless tobacco (SLT) use is common among women, smoking among women is increasing [8],[9]. In Southeast Asia, tobacco is used in diverse forms, including cigarettes or bidis (dried tobacco rolled in paper or leaf), SLT such as chewing khaini (tobacco with slaked lime and aromatic spices), surti (dried tobacco leaves for chewing), or paan masala (tobacco with aromatic spices), sucking gutkha (mixture of tobacco and molasses available in small sachets), applying gul or gudaku as dentifrice, and inhaling nas and naswar (nasal inhalation of tobacco powder) [10]. Bidis are popular in Bangladesh, India, Maldives, Nepal, and Sri Lanka, whereas cheroots are popular in Myanmar, and roll-your-own cigarettes (in palm leaves or paper) are popular in Thailand and Timor Leste. In Bangladesh, India, and Nepal, use of gul, gudaku, mishri, masher, lal dantamanjan as dentrifice, and nas/naswar is common [11]. SLT use in various forms is directly responsible for oropharyngeal cancers [12],[13].
Socio-economic differentials in tobacco use have existed in both developed [14],[15] and developing countries [16]-[18]. Studies have reported that tobacco consumption rates are higher in lower socioeconomic classes and less-educated groups [16],[17],[19]. Moreover, smoking prevalence is lower among women worldwide, particularly in South and Southeast Asia [20]. Therefore, assessing socio-economic differentials of tobacco use in Southeast Asia by population-based surveys will provide information about effectiveness of tobacco control measures and aid policymaking. The global tobacco surveillance system [21], World Health Organization (WHO) STEPS program [22], and WHO World Health Surveys (WHS) [23] have provided such information. However, these surveys cover several countries from various regions, but not all of the countries in a region. Moreover, the literature from these surveys has emphasized smoking and reported determinants of tobacco use [16],[17],[24], but not about SLT use, which is prevalent in South and Southeast Asia [11]. Demographic and Health Surveys (DHS) collect information about tobacco use in nationally representative samples of men and women and have provided national estimates of tobacco use for Nepal [25], India [26],[27], sub-Saharan Africa [18], and other countries [28]. We aimed to provide national estimates on prevalence and social determinants of tobacco smoking and smokeless tobacco use in South and Southeast Asian countries.
All analyses were done for men and women separately in each country. Descriptive analyses were done for smoking and SLT use. Overall weighted prevalence estimates for tobacco smoking and SLT use were calculated by including sample weights to account for the complex sampling design of DHS. Weighted prevalence estimates of smoking and SLT use were calculated according to age groups, religion, place of residence, marital status, education, and wealth quintiles. Binary logistic regression analyses were done to assess demographic (age was entered as continuous variable) and socio-economic factors associated with smoking and SLT use by SVY command on STATA/IC version 10 [33]. Beta-coefficients, their 95% confidence intervals, and p-values were calculated.
Our report using DHS datasets provided national-level estimates and information about the pattern of tobacco use in nine countries in the South and Southeast Asia region. Our disaggregated analyses by gender and type of tobacco use demonstrated that pattern of tobacco consumption has cross-country and intracountry variations. In each country, tobacco consumption among men and women was unequally distributed in all demographic and socio-economic groups. Tobacco use among women was very low in all countries, but smoking was higher in Nepal and SLT use higher in India than other countries. Prevalence of smoking and SLT use among men was almost equal in India and Nepal, but among Bangladeshi men, smoking was higher than SLT use. Prevalence of smoking among men was very high in Indonesia, Timor Leste, and Maldives while SLT use was very low. In all countries, significant associations between age, education, and wealth for both smoking and SLT use highlights the existence of social disparities in tobacco use.
Prevalence estimates were comparable to DHS-based estimates for India [26] and Nepal [25] and were much higher than estimates for India and Nepal in GATS [17],[34], but prevalence in Cambodia was lower compared to another national survey [35]. Only three (India, Bangladesh, and the Philippines) of the nine countries that had also participated in the first wave of GATS did not allow comparison of prevalence in all GATS countries [17],[34]. Moreover, our estimates cannot be compared with those of GATS and WHS, which defined current smoking as smoking of any form of tobacco either daily or occasionally [16],[34], while the Global Burden of Disease (GBD) study defined daily smoking as smoking any type of tobacco product at least once per day [5]. Our estimates for the current smoking rate among men in Indonesia and Timor Leste were approximately 70%, whereas GBD reported rates as
Our findings that current smoking is prevalent from the age of 15 years onwards but was higher in older age groups which is similar to results of previous surveys [16]-[18],[34]. This may be due to a cohort effect (i.e., smoking was less likely to be initiated in more recent decades). This means that more attention should be paid to young men in Indonesia, Maldives, and Bangladesh, where prevalence rates of smoking were alarmingly high. Some think that tobacco companies have been aggressively marketing to young people in these countries, particularly in Indonesia [38]. A protective effect of education on smoking, after controlling for other factors, was consistent with results of previous studies [16]-[18]. However, association of smoking with wealth index was consistent for women in most countries, but not for men, highlighting that smoking behavior may be context-specific, needing country-level analysis like that seen in the GATS report [17] but not in other reports from WHS [16] and DHS [18]. In developed countries, the smoking epidemic began among the rich and educated and later spread to lower socio-economic groups [39], but in developing countries the less educated may have taken up smoking, due to lack of awareness about health risks [40]. Lack of association of wealth index with smoking in some countries could be explained by parental influences, peer pressure [41], and cultural acceptance of smoking [42]. Significantly higher rates of smoking among urban residents have been reported [18],[43]; in our study a higher prevalence of tobacco use among rural residents was not significant for men (with multivariate analysis). We found that socio-demographic factors associated with SLT use were increasing age, lower education, and poverty among both men and women, which is similar to determinants of current smoking in our study and studies from India [26], Nepal [25], and Bangladesh [44], which analyzed SLT use separately. These findings are also similar to multicountry surveys that reported social determinants of tobacco use [17] or smoking only [16],[18]. 2ff7e9595c