|Year : 2017 | Volume
| Issue : 3 | Page : 584-588
Education differential in relation to tobacco use and its predictors across different regions of India
Deepak Sharma1, Sonu Goel2, Pranay Lal3
1 Department of Community Medicine, Government Medical College and Hospital, Chandigarh, India
2 School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
3 International Union against Tuberculosis and Lung Disease (The Union), New Delhi, India
|Date of Web Publication||24-May-2018|
Dr. Deepak Sharma
Department of Community Medicine, Government Medical College and Hospital, Chandigarhw
Source of Support: None, Conflict of Interest: None
BACKGROUND: Tobacco use and education of an individual are linked to each other. Educated people are more likely to practice healthy behaviors and are aware of the harms of tobacco use. This paper uses the Global Adult Tobacco Survey data (GATS-India) to study the education differential associated with tobacco use and its predictors across India. METHODOLOGY: Secondary data analysis was conducted for GATS conducted in 2009–2010 in India. Data for “illiterate” and “literate” study subjects were analyzed according to study subject's “tobacco consumption pattern,” their “quitting behavior,” “exposure to second hand smoke (SHS)” and “observing health warnings on tobacco products.” RESULTS: Tobacco smokers and smokeless tobacco users were more likely to be illiterate (odds ratio [OR] for smoking tobacco = 1.2; for smokeless tobacco = 1.5) as compared to their counterparts. Significantly, more illiterate initiated smoking tobacco (OR = 1.1; 1.02–1.26) and smokeless tobacco habit (OR = 1.3; 1.21–1.44) before 17 years of age. Illiterate people were less likely to try quitting tobacco (smoking tobacco = OR = 0.8; 0.79–0.94; smokeless tobacco = OR = 0.7; 0.70–0.81) and also less likely to think of quitting tobacco in near future (smoking tobacco = OR = 0.6; 0.59–0.71; smokeless tobacco = OR = 0.6; 0.57–0.66). Illiterate people were more likely to be exposed to SHS at home (OR = 1.8; 1.7–1.9) and less likely to notice health warnings on cigarette packets (OR = 0.2; 0.26–0.28) and smokeless tobacco pouches (unadjusted OR = 0.5; 0.49–0.53). CONCLUSION: The results confirm that education differential exists for tobacco use and its determinants in India. It is recommended that all people of our country should have access to quality education. Policy makers should target uneducated people so as to reverse the tobacco epidemic.
Keywords: Education, quit, second hand smoke, tobacco
|How to cite this article:|
Sharma D, Goel S, Lal P. Education differential in relation to tobacco use and its predictors across different regions of India. Indian J Cancer 2017;54:584-8
|How to cite this URL:|
Sharma D, Goel S, Lal P. Education differential in relation to tobacco use and its predictors across different regions of India. Indian J Cancer [serial online] 2017 [cited 2019 Oct 15];54:584-8. Available from: http://www.indianjcancer.com/text.asp?2017/54/3/584/233149
| » Introduction|| |
Tobacco use is the leading cause of preventable death and illness in India. The harmful effects of tobacco use include problems such as cardiovascular disease, chronic lung disease, stroke, and cancers., There is an evident social stratification in patterns of tobacco use with regards to educational attainment, occupational status, income level, and gender of an individual. Hosseinpoor et al. in a review of data from low middle income countries revealed that there were higher smoking rates among the less educated and an inverse relation existed between income and smoking. Pradhan et al. in their study reported the higher prevalence of tobacco use among males than female counterparts.
Among all the markers of social stratification, education is the most well-established one. It is related to health literacy and healthy behaviors. It has been documented that educated people are more likely to understand the harms of tobacco use and thus decide to stay away from this habit. Hosey et al. observed that higher education was associated with lower odds for daily tobacco use. Gavarasana et al. reported the fact that among illiterates the smoking rate was high and around half of them were ignorant of health effects of smoking. Further, educated people are more likely to observe health warnings on tobacco packs. Education influences the treatment seeking behavior of an individual wherein they are more likely to seek help of a counselor/doctor for quitting tobacco use. Breslau and Peterson in their study on smoking cessation in young adults inferred that low education decreased the likelihood of tobacco cessation. Similar finding was reported by Gilman et al. in their study.
Although there is an unequivocal evidence of role of education in tobacco use, still there is a still a need to generate more evidence regarding this public health problem. Understanding this pattern is essential for designing specific tobacco strategies for India. With this background, the aim of the present study is to study the education differential associated with tobacco use and its predictors across different regions of India.
| » Methodology|| |
The present study used Global Adult Tobacco Survey-India (GATS-India) 2009–10 data for secondary data analysis. This nationally representative household survey covered population aged 15 years and above and was conducted in 29 states and 2 Union Territories (UTs) of India. The survey covered domains such as tobacco use (smoking and smokeless tobacco), economics of tobacco, exposure to second-hand smoke (SHS), cessation attempts, exposure to media messages on tobacco use, and knowledge, attitudes, and perceptions toward tobacco use.
The main dependant variable in the present study was “education” categorized into “illiterate” and “literate.” The independent variables were “current tobacco users (smoking and smokeless),” “age of initiation of tobacco use,” “quitting behavior,” “exposure to SHS” and “observing health warnings on tobacco products.” For assessing the “current tobacco users” responses to the following questionnaire items was used: (a) “Do you currently smoke tobacco” (b) Do you currently use smokeless tobacco? The “age of initiation” variable was assessed from the following questions: (a) How old were you when you first started smoking tobacco daily? (b) How old were you when you first started using smokeless tobacco daily? The tobacco quitting behavior of the study subjects were evaluated by asking the study subjects whether they “tried to stop smoking/smokeless tobacco during the past 12 months” and whether they are “thinking of quitting tobacco in the coming future.” The “exposure to SHS” was assessed by asking them the practices about smoking inside their home. For the variable “observing health warning on tobacco pack” responses to the following questions was used: “In the past 30 days, did you notice any health warnings on cigarette packages?” and in the past 30 days, did you notice any health warnings on smokeless tobacco product packages?
Data were analyzed using Epi Info 6.04 software for windows (Centre for Disease Control, Atlanta, GA, USA). Differences in proportions between the illiterate and literate for tobacco consumption, their quit attempts, exposure to SHS, and noticing health warnings on tobacco products were tested using Pearson's Chi-square test. Unadjusted odds ratios (UORs) with 95% confidence intervals were reported.
| » Results|| |
Out of 69,296 study subjects, 69,156 (99.7%) disclosed their education level (missing entries 140). Out of 69,156 study subjects, 11,559 were current smokers (16.7%), 16,762 were current smokeless tobacco users (24.2%) and 4063 (5.8%) were dual users of tobacco. Significantly, tobacco smokers were more likely to be illiterate (UOR = 1.2; 1.17–1.28) as compared to nontobacco users. Similarly, smokeless tobacco users were more likely to be illiterate (UOR = 1.5; 1.48–1.59) as compared to their counterparts. Among the study subjects, significantly more illiterate initiated tobacco smoking (UOR = 1.1; 1.02–1.26) and smokeless tobacco use habit (UOR = 1.3; 1.21–1.44) before 17 years of age.
Comparatively, illiterate people were less likely to try quitting tobacco (smoking tobacco = UOR = 0.8; 0.79–0.94; smokeless tobacco = UOR = 0.7; 0.70–0.81) and think of quitting tobacco in the next few months (smoking tobacco = UOR = 0.6; 0.59–0.71; smokeless tobacco = UOR = 0.6; 0.57–0.66). As compared to literates, the illiterate people were more likely to be exposed to SHS at home (UOR = 1.8; 1.7–1.9) and less likely to notice health warnings on cigarette packets (UOR = 0.2; 0.26–0.28) and smokeless tobacco products (UOR = 0.5; 0.49–0.53) [Table 1].
|Table 1: Association between domains of tobacco use and literacy levels in India|
Click here to view
Region-wise analysis shows that comparatively there were higher illiterate “smokers” (odds ratio [OR] =1.7; 1.5–1.9) and “smokeless tobacco users” (OR = 3.5; 3.1–3.9) in Southern region of India. In Northern (OR = 0.7; 0.5–0.8), Eastern (OR = 0.7; 0.5–0.9) and Western region of India (OR = 0.5; 0.3–0.7); significantly, more illiterates people initiated smoking at an earlier age as compared to their counterparts. Across all regions of India, illiterate tobacco users were less likely to “try quitting tobacco,” “think of quitting tobacco in near future,” and “notice health warning on tobacco products” and “exposed to SHS at home association of illiteracy and tobacco use predictors across regions of India is presented in [Table 2].
|Table 2: Tobacco use predictors for illiteracy across different regions of India|
Click here to view
| » Discussion|| |
The current study has found an association between literacy and tobacco use across different regions of India. It reinforces the notion that illiteracy is associated with higher proportion of tobacco users, lower tobacco quit attempts, higher exposure to SHS at home and less likely to observe health warnings on tobacco products. This study observed that illiteracy was significantly associated with tobacco use. This is consistent with other studies conducted in India and abroad. Gupta et al. in a North Indian inferred that tobacco use was more among illiterates. Rani et al. did secondary data analysis of a nationally representative population based household survey of India and reported that tobacco consumption was the highest in the least educated. Sinalkar et al. in Maharashtra reported an inverse relation of tobacco with educational level. Similar finding has been reported in other studies conducted by Khatri et al. in Nepal and Alam et al. in Pakistan., This association may be because early education in school exposes the child to the concepts of problem-solving and critical thinking, which helps them think about the consequences of their actions. They thus may become capable of understanding the harms of tobacco use and decide wisely to shy away from this harmful habit.
In the current study, illiterate people had more odds of initiating tobacco use at an early age. This may be due to multiplicity of reasons like increased peer influence and curiosity among illiterates as compared to literates because of unawareness, the likelihood of more myths and magical properties of tobacco use. Further, this study inferred that illiterate people were less likely to try quitting tobacco and think of quitting tobacco as compared to counterparts. Similar to this finding, Garg et al. reported that low educational status was associated with poor quitting behavior. Islam et al. inferred that intention to quit was more among more educated person. Rosenthal et al. reported that less education was associated with difficulty in quitting tobacco. The present study revealed that education is a significant predictor of exposure levels to SHS at home. Singh and Sahoo in India; Sein et al. in Mayanmar and Palipudi et al. in Bangladesh report have reported similar association., This association may be because illiterate subjects have limited knowledge about harmful effects of SHS on nonsmokers and thus may not be able to resist active smokers.
According to the Indian Smoke-free law, Cigarettes and Other Tobacco Products Act there is a mandatory provision of health warning on tobacco products. The present study found that illiterates were less likely to notice health warnings on cigarette packets and smokeless tobacco pouches. This finding is supported by a study conducted by Shang et al. wherein it was reported that lesser educated respondents were less likely to be exposed to health warnings.
The major strength of our study is using GATS data which has a nationwide representative sample and a robust standardized methodology. The limitations are the self-reported nature of data collection which may underestimate or exaggerate the study findings and some limited missing values in the data set.
| » Conclusion|| |
Results of this study confirm that education differential exists for tobacco use and its predictors across India. It is recommended that all people of our country should have access to quality education. This will help them in developing creative thinking and decision-making skills which are vital for prohibiting the uptake of tobacco use. Education empowers people to choose an appropriate behavior which is beneficial for maintain a positive health lifestyle. Further policy makers in India should focus more on the uneducated people so as reverse the tobacco epidemic in India.
We acknowledge our sincere gratitude to 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; Centers for Disease Control and Prevention (CDC); Atlanta; Johns Hopkins Bloomberg School of Public Health (JHSPH) and Research Triangle Institute (RTI) International for their dedicated efforts towards conducting and publishing the results of Global Adult Tobacco Survey (GATS) 2009-2010. This present study would not have been possible without using the Global Adult Tobacco Survey (GATS) data.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
Prabhakar B, Narake SS, Pednekar MS. Social disparities in tobacco use in India: The roles of occupation, education and gender. Indian J Cancer 2012;49:401-9.
] [Full text]
Hosseinpoor AR, Parker LA, Tursan d'Espaignet E, Chatterji S. Social determinants of smoking in low- and middle-income countries: Results from the World Health Survey. PLoS One 2011;6:e20331.
Pradhan PM, Niraula SR, Ghimire A, Singh SB, Pokharel PK. Tobacco use and associated factors among adolescent students in Dharan, Eastern Nepal: A cross-sectional questionnaire survey. BMJ Open 2013;3. pii: E002123.
Thankappan KR, Thresia CU. Tobacco use and social status in Kerala. Indian J Med Res 2007;126:300-8.
] [Full text]
Oswal KC, Raute LJ, Pednekar MS, Gupta PC. Are current tobacco pictorial warnings in India effective? Asian Pac J Cancer Prev 2011;12:121-4.
Hosey GM, Samo M, Gregg EW, Barker L, Padden D, Bibb SG. Association of socioeconomic position and demographic characteristics with cardiovascular disease risk factors and healthcare access among adults living in Pohnpei, Federated States of Micronesia. Int J Chronic Dis 2014;2014:595678.
Gavarasana S, Gorty PV, Allam A. Illiteracy, ignorance, and willingness to quit smoking among villagers in India. Jpn J Cancer Res 1992;83:340-3.
Stewart DW, Adams CE, Cano MA, Correa-Fernández V, Li Y, Waters AJ, et al.
Associations between health literacy and established predictors of smoking cessation. Am J Public Health 2013;103:e43-9.
Breslau N, Peterson EL. Smoking cessation in young adults: Age at initiation of cigarette smoking and other suspected influences. Am J Public Health 1996;86:214-20.
Gilman SE, Martin LT, Abrams DB, Kawachi I, Kubzansky L, Loucks EB, et al.
Educational attainment and cigarette smoking: A causal association? Int J Epidemiol 2008;37:615-24.
Gupta V, Yadav K, Anand K. Patterns of tobacco use across rural, urban, and urban-slum populations in a North Indian community. Indian J Community Med 2010;35:245-51.
] [Full text]
Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4.
Sinalkar DR, Kunwar R, Bagal R. Tobacco consumption and its association with education among women residing in a rural area of Maharashtra: A cross-sectional study. Med J Armed Forces India 2012;68:335-8.
Khatri RB, Mishra SR, Khanal V. Tobacco use among rural Nepalese women: Cross-sectional community based study. Indian J Cancer 2015;52:699-704.
] [Full text]
Alam AY, Iqbal A, Mohamud KB, Laporte RE, Ahmed A, Nishtar S, et al.
Investigating socio-economic-demographic determinants of tobacco use in Rawalpindi, Pakistan. BMC Public Health 2008;8:50.
Garg A, Singh MM, Gupta VK, Garg S, Daga MK, Saha R, et al.
Prevalence and correlates of tobacco smoking, awareness of hazards, and quitting behavior among persons aged 30 years or above in a resettlement colony of Delhi, India. Lung India 2012;29:336-40.
] [Full text]
Islam K, Saha I, Saha R, Samim Khan SA, Thakur R, Shivam S. Predictors of quitting behaviour with special reference to nicotine dependence among adult tobacco-users in a slum of Burdwan district, West Bengal, India. Indian J Med Res 2014;139:638-42.
] [Full text]
Rosenthal L, Carroll-Scott A, Earnshaw VA, Sackey N, O'Malley SS, Santilli A, et al.
Targeting cessation: Understanding barriers and motivations to quitting among urban adult daily tobacco smokers. Addict Behav 2013;38:1639-42.
Singh A, Sahoo N. Urban-rural differentials in the factors associated with exposure to second-hand smoke in India. BMJ Open 2013;3:e003542.
Sein AA, Than Htike MM, Sinha DN, Kyaing NN. Exposure to second-hand tobacco smoke among adults in Myanmar. Indian J Cancer 2012;49:410-8.
] [Full text]
Palipudi KM, Sinha DN, Choudhury S, Mustafa Z, Andes L, Asma S, et al.
Exposure to tobacco smoke among adults in Bangladesh. Indian J Public Health 2011;55:210-9.
] [Full text]
Shang C, Huang J, Cheng KW, He Y, Chaloupka FJ. The association between warning label requirements and cigarette smoking prevalence by education-findings from the global adult tobacco survey (GATS). Int J Environ Res Public Health 2017;14:98.
[Table 1], [Table 2]