|Year : 2012 | Volume
| Issue : 4 | Page : 393-400
Profile of dual tobacco users in India: An analysis from Global Adult Tobacco Survey, 2009-10
PC Gupta1, CS Ray1, SS Narake1, KM Palipudi2, DN Sinha3, S Asma2, G Blutcher-Nelson2
1 Healis Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra, India
2 Office on Smoking and Health, Centers for Disease Control and Prevention, Atlanta, USA
3 World Health Organization, Regional Office for South East Asia, New Delhi, India
|Date of Web Publication||26-Feb-2013|
C S Ray
Healis Sekhsaria Institute for Public Health, Navi Mumbai, Maharashtra
Source of Support: South-East Asia Regional Office of the World Health Organization., Conflict of Interest: None
Introduction: Individuals who use both smoked and smokeless tobacco products (dual tobacco users) form a special group about which little is known. This group is especially relevant to India, where smokeless tobacco use is very common. The aim of this study was to characterise the profile of dual users, study their pattern of initiation to the second product, their attitudes toward quittingas well as their cessation profile. Methods and Materials: The GATS dataset for India was analyzed using SPSS; . Results: In India, dual tobacco users (42.3 million; 5.3% of all adults; 15.4% of all tobacco users) have a profile similar to that of smokers. Some 52.6% of dual users started both practices within 2 years. The most prevalent product combination was bidi-khaini (1.79%) followed by bidi-gutka (1.50%), cigarette-khaini (1.28%), and cigarette-gutka (1.22%). Among daily users, the correlation between the daily frequencies of the use of each product was very high for most product combinations. While 36.7% of dual users were interested in quitting, only 5.0% of dual users could do so. The prevalence of ex-dual users was 0.4%. Conclusion: Dual users constitute a large, high-risk group that requires special attention.
Keywords: Cessation, dual/mixed tobacco users, India, initiation, national survey, socio-demographic profile
|How to cite this article:|
Gupta P C, Ray C S, Narake S S, Palipudi K M, Sinha D N, Asma S, Blutcher-Nelson G. Profile of dual tobacco users in India: An analysis from Global Adult Tobacco Survey, 2009-10. Indian J Cancer 2012;49:393-400
|How to cite this URL:|
Gupta P C, Ray C S, Narake S S, Palipudi K M, Sinha D N, Asma S, Blutcher-Nelson G. Profile of dual tobacco users in India: An analysis from Global Adult Tobacco Survey, 2009-10. Indian J Cancer [serial online] 2012 [cited 2019 Jul 24];49:393-400. Available from: http://www.indianjcancer.com/text.asp?2012/49/4/393/107746
| » Introduction|| |
While globally and in India, most tobacco users stick to only smoking or smokeless products, a proportion of them concurrently use both the forms. These users may be referred to as dual tobacco users.
Dual tobacco users form a subset of tobacco users that has not been well studied in India. All earlier reports on dual tobacco use in India were confined to small regions, but this report uses nationally representative data. India is one of over 13 low and middle income countries around the world where the first wave of the Global Adult Tobacco Survey (GATS) has been conducted. Among three south-East Asian countries surveyed, India has the second highest prevalence of dual tobacco use (5.3%) after Bangladesh (8.7%),  while Thailand has a prevalence of 3.2%. 
Dual use of tobacco increases the risk of oral, pharyngeal, and esophageal cancers  as well as heart diseases, , over and above the risk experienced by single tobacco users, especially respect to smokers. At the same time, many dual users in India have had more difficulty quitting tobacco use than single type tobacco users.  This shows that dual users form a special high-risk group. Hence, it is important to study them in detail.
This paper presents the profile of dual tobacco users in India, describes their pattern of initiation to both of these products, their attitudes toward quitting and the prevalence of cessation of both products.
| » Materials and Methods|| |
In this paper, a dual tobacco user is defined as a person who concurrently uses both smoking and smokeless forms of tobacco. The term "mixed tobacco user" has been used previously to describe such users.  The term "single user" denotes a person who either smokes or uses smokeless tobacco products exclusively. Alternately, the terms "exclusive smoker" or "exclusive smokeless tobacco user" also indicate a person who uses only one form of tobacco, smoked or smokeless.
The GATS was conducted in India during 2009-10  under the auspices of the Ministry of Health and Family Welfare in collaboration with the World Health Organization and with technical support from the Centers for Disease Control and Prevention, USA. The survey was carried out in 29 states and 2 Union Territories (Chandigarh and Puducherry) and covered 99.9% of the population of the country. The GATS measured tobacco use by self-report alone, with no biochemical verification.
The report of the GATS for India described the questionnaire, survey methodology, and analysis in great detail.  The GATS India data were analyzed to obtain the profile of dual tobacco users in India using SPSS version 18.0 for complex samples. However, the socio-demographic and state-wise profiles of dual tobacco use were obtained from the GATS India country report.  The objectives of this analysis were to describe the association between two types of use, the pattern of initiation to the second product and to find out the product combinations used. Unless otherwise indicated, weighted sample data, as was done for the original report, was used for estimating prevalence and confidence intervals in order to respect the complex sample design.
| » Results|| |
In the GATS India, 69,296 individuals aged ≥15 years (defined as adults) were interviewed comprising of 33,767 males and 35,529 females, with an overall response rate of 91.8. 
The overall prevalence of dual tobacco use among adults in India was 5.3%. The corresponding estimated total number of dual users among adults in India was 42.3 million (including 38.1 million males and 4.2 million females), which is about 15.4% or one-sixth of the total of 274.9 million adult tobacco users. 
Prevalence and proportions
Among smokers, 38.0% also used smokeless tobacco (whereas 23.9% of non-smokers used smokeless tobacco) and, among smokeless tobacco users, 20.5% also smoked (whereas 11.7% of non-users of smokeless tobacco smoked).
The socio-demographic profile of dual users is shown in [Table 1]. Among men, the prevalence of dual use was 9.3% and, among women, it was 1.1%,  giving a male to female ratio of 8.5 to 1.
|Table 1: Prevalence of dual tobacco users among adults aged ≥15 years in India by socio-demographic characteristics (GATS, 2009-10)|
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The age distribution of dual users showed that the prevalence was highest in the age group 25-44 years (6.4%). Adults with some primary school education showed the highest prevalence of dual use (8.3%) compared to individuals with other levels of education. The employed (8.3%) had the highest prevalence of dual use and students had the lowest (1.4%). Dual use prevalence was 3.6% in urban and 6.0% in rural areas.
Region and state-wise prevalence
Dual tobacco use was most frequently reported in the north eastern region (9.8%), followed by the Eastern (7.9%) and central (6.6%) regions. In the central region, report of dual use was 8.8% in Madhya Pradesh while in the eastern region, 9.5% was found in Bihar (9.5%). In the north-eastern region, 20.0% was found in Nagaland [Table 2].
|Table 2: Differences in prevalence of dual tobacco users among adults aged ≥15 years in India by region and state (GATS, 2009-10)|
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In most states, where both smoking and smokeless tobacco use prevalence were higher, dual use was higher.
Association between smoking and smokeless use
[Table 1] and [Table 2] provide odds ratios for chewers being smokers as compared to non-chewers being smokers adjusted for socio-demographic characteristics. There was a four-fold (OR = 3.97) higher risk in the lower age group (15-24 years) and a thirteen-fold higher risk among students (OR = 12.76). Significant negative association (OR <1.0) was observed in the higher age groups (45-64, 65+), in adults with no formal education and in the states of Mizoram and Uttarkand. Associations most other states were positive.
Product combination profile
Since a large variety of smoking and smokeless tobacco products are used in India, it was interesting to look at combinations of products used by dual users. Users of both bidis and khaini formed the largest group (1.8%) [Table 3]. The next largest group was users of bidis and gutka (1.5%). These were followed by users of cigarettes and khaini (1.3%) and then by users of cigarettes and gutka (1.2%). The combination of bidi and khaini was used by one-third of dual users (34%).
|Table 3: The prevalence (%) of use of tobacco product combinations among adults aged ≥15 years in India (GATS, 2009-10)|
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Pattern of initiation
Among all dual users, 31.6% had started using both products in the same year; 43.0% started smoking more than a year before starting smokeless tobacco and the remaining 25.4% started using smokeless tobacco more than a year before smoking. Over half (52.6%) started using the second product within 2 years of starting the first. The distribution of the difference in the ages of initiation of the two different product types (smoking minus smokeless) was fairly symmetrical [Figure 1].
|Figure 1: Pattern of initiation: Proportion of dual users in India (aged ≥15 years) plotted against the difference in the age of initiation of the two tobacco products (smoking minus smokeless) (GATS, 2009-10)|
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Over half of current dual users (54.6%) used both products daily. Two-thirds of current dual users (66.7%) smoked daily, while nearly four-fifths (79.5%) used smokeless tobacco daily. Just 8.4% used both products only occasionally [Table 4].
|Table 4: Proportions of daily and non-daily users of the two types of products among dual tobacco users aged ≥15 years in India (GATS, 2009-10)|
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Frequency of use per day
There was little difference between the daily frequency of smoking among dual users as compared to exclusive smokers. For example, among daily dual users, the mean number of cigarettes smoked per day was 4.3 pieces, whereas, among current daily cigarette smokers, it was 5.4 cigarettes. For smokeless tobacco use, there was even less difference between the number of times daily exclusive users used smokeless tobacco and daily dual users used it in the different forms [Table 5].
|Table 5: Number of times smoking and smokeless tobacco used per day by dual users aged ≥15 years in India (GATS, 2009-10; un-weighted)|
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There was a strong positive correlation between daily frequency of smoking and that of smokeless tobacco use among everyday dual users, as measured by Pearson's product moment correlation coefficient [Table 6]. Correlation coefficients were positive and highly significant for almost all product combinations.
|Table 6: Correlation between the frequency of smoking and of smokeless tobacco use among daily dual users aged ≥15 years in India for different combinations of smoked and smokeless tobacco products (GATS, 2009-10)|
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Cessation of tobacco use
Some 36.7% of dual users were interested in quitting both forms of tobacco use (in the next 30 days, in the next 12 months, or someday in the future). On other hand, 11.2% of dual users were interested in quitting smoking only and 7.6% of dual users were interested in quitting use of only smokeless tobacco [Figure 2]. Thus, it was seen that, among dual users who were interested in quitting, by far, the majority wanted to quit both forms of tobacco use.
|Figure 2: Proportion of dual tobacco users among adults aged≥15 years in India who were interested in quitting, made quit attempts in the past 12 months or were ex-dual users among ever dual users (GATS, 2009-10)|
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Among current and former dual tobacco users, 23.9% made an attempt to quit both forms of tobacco use in the past 12 months before the survey. Another 14.6% attempted to quit smoking only and 8.4% tried to quit smokeless tobacco only. Among ever dual users, the proportion of ex-users of both products was 5.0%, the proportion of those who quit only smoking was 5.3%, and the proportion who had quit only smokeless was 2.6% [Figure 2]. The prevalence of past dual tobacco users among all adults was 0.4%, while the prevalence of past exclusive smokers was 2.5% and the prevalence of past exclusive smokeless tobacco users was 1.8%.
| » Discussion|| |
There are several reasons why it is important to pay attention to dual tobacco users. First, they appear to face greater health risks than individuals who use single products. Several studies show higher health risks in dual tobacco users compared to exclusive smokers or chewers. In a case-control study in India, dual tobacco users had over triple the risk for oral cancer (OR dual users = 8.5, 6.1-11.9) as compared to exclusive smokers (OR = 2.5, 1.9-3.1), while exclusive chewers (OR = 9.3, 6.8-12.7) had a similar risk. In the same study, dual users had at least 20% higher risks for pharyngeal and oesophageal cancers than single users. 
In the INTERHEART case-control study in 52 countries, current smokers who also chewed tobacco had the highest risk of myocardial infarction (OR = 4.1, 3.0-5.6) as compared to exclusive current smokers (OR = 3.0, 2.8-3.1) or exclusive chewers (OR = 2.2, 1.4-3.5). 
In addition, in a case-control study from Bangladesh, a much higher risk of coronary heart disease was found in ever dual users [OR = 17.4 (5.2-58.1)] as compared to exclusive ever smokers (OR = 3.7, 1.7-8.2) or users of smokeless tobacco (OR = 2.8, 1.1-7.3). 
Second, there is evidence that cessation of dual use seems to be more difficult than cessation of single product use. In a 5-year intervention study, among males, only 3.3% of dual tobacco users had stopped, while 6.2% of exclusive smokers and 10.2% of exclusive chewers had stopped their use of tobacco. The proportion of women dual users who were able to quit was also much smaller than that of single users who quit. 
Historically, dual use of tobacco by individuals has been reported in India for almost 50 years. An early cross-sectional study carried out during 1964-66 in Mainpuri district, Uttar Pradesh, reported that there were 12.1% adult dual tobacco users, 15.2% exclusive smokeless tobacco users, and 28.7% exclusive smokers.  A survey in rural areas of five districts of India (Srikakulam in Andhra Pradesh, Darbhanga and Singhbhum in Bihar, Bhavnagar in Gujarat, and Ernakulam in Kerala), during 1966-69, reported that the highest prevalence of dual use in Darabhanga district of Bihar, with 26.2% among men and 3.8% among women (≥15 years). The lowest prevalence of dual use was in Srikakulam district of Andhra Pradesh with 9.9% among men and 2.7% among women.  In another large rural house-to-house survey in rural Pune district of Maharashtra during 1968-71, the prevalence of dual use among men was only 2.4% and it was not detected among women.  In a later survey in Bhavnagar district of Gujarat in 1998, there were 4.8% men using both types of tobacco products.  In these early studies, dual use was generally high in those areas where smokeless tobacco use was high (e.g., Bihar and Kerala), with the exception of Maharashtra where smoking prevalence was low.
The gender distribution of dual tobacco users in India (M:F = 8.5) is highly skewed toward males because the prevalence of smoking among women is quite low. It was interesting that the GATS showed that dual use was commonest in younger age-groups, similar to the scenario in the United States. 
Dual use is more prevalent among males, people with less education, individuals who are employed,s and somewhat more prevalent among rural residents. Odds ratios show a very high risk for students who are using smokeless tobacco of also being smokers, compared to non-smokeless tobacco users being smokers (12.76%). A high risk was also seen for the youngest age-group (15-24 years). The age difference for initiation of the two products was very narrow (<2 years) for over half of dual users. For those dual users who did not start in the same year, it was more common to start smoking first, a finding somewhat similar to that in Sweden.  There was however, no evidence that this was for the purpose of smoking cessation.
The fact that daily dual users in India are smoking and consuming smokeless tobacco at rates similar to those of single tobacco users clearly indicates that they are ingesting a much higher quantity of nicotine and other toxic chemicals than single users. The result that the proportion of former dual users was one-sixth the size of the proportion of former exclusive smokers and less than one-fourth of the proportion of former exclusive smokeless tobacco users is indicative of a higher level of tobacco dependence among dual users compared to single users.
The results show that, in general, smokeless tobacco users are significantly more likely to also be smokers than are non-smokeless tobacco users. The fact that students who use smokeless tobacco (also young persons) are far more likely to also be smokers compared to non-smokeless tobacco user students is highly troubling from the public health point of view. Tobacco control policies need to be directed to address this issue. Also, the most commonly used products in combination are the cheaper ones; thus, the price policies of all tobacco products need special attention to make tobacco products less affordable.
| » Conclusion|| |
In India, dual tobacco users constitute a sizeable number and a specific high-risk group. In view of higher disease risks and more difficulty in quitting, this group needs special attention for further research and intervention. Tobacco control policies aimed at controlling both forms of tobacco use are required to reduce dual tobacco use.
| » Acknowledgment|| |
The authors recognise that this work would not have been possible without the data collected for the Global Adult Tobacco Survey (GATS) 2009-2010 in India. We gratefully acknowledge the contributions of the Ministry of Health and Family Welfare (MoHFW), Government of India; the International Institute for Population Sciences (IIPS), Mumbai; the World Health Organization (WHO) Country Office for India, WHO South-East Asia Regional Office (SEARO); Centers for Disease Control and Prevention (CDC); CDC Foundation, Atlanta; Research Triangle Institute (RTI) International and Johns Hopkins Bloomberg School of Public Health (JHSPH) for their dedicated efforts towards conducting the survey, analysing the data, and reporting the findings.
| » Disclaimer|| |
The views expressed in this article are solely those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the GATS partner organizations.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]
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