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|Year : 2010 | Volume
| Issue : 5 | Page : 91--100
Sociodemographic correlates of male chewable smokeless tobacco users in India: A preliminary report of analysis of national family health survey, 2005-2006
T Rooban, J Elizabeth, KR Umadevi, K Ranganathan
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, 2/102 East Coast Road, Uthandi, Chennai - 600 119, India
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, 2/102 East Coast Road, Uthandi, Chennai - 600 119
Objective : To estimate the prevalence, the socioeconomic and demographic correlates of chewable smokeless tobacco consumption among males in India. Design : A cross-sectional, nationally representative population-based household survey. Subjects : 74,369 males aged 15-54 years who were sampled in the National Family Health Survey-3 (2005-2006). Data on tobacco consumption were elicited from male members in households selected for the study. Materials and Methods : The prevalence of various smokeless tobacco use currently was used as outcome measures. Simple and two-way cross tabulations and univariate logistic regression analysis were the main analytical methods. Results : Thirty-four percent of the study population (15 years or older) used chewable smokeless tobacco. Smokeless tobacco consumption was significantly higher in poor, less educated, scheduled castes, and scheduled tribe populations. The prevalence of tobacco consumption showed variation with types. The prevalence of chewing also varied widely between different states and had a strong association with an individual«SQ»s sociocultural characteristics. Conclusion : The findings of the study highlight that an agenda to improve the health outcomes among the poor in India must include effective interventions to control tobacco use. Failure to do so would most probably result in doubling the burden of diseases-both communicable and noncommunicable-among India«SQ»s teeming poor. There is a need for periodical surveys using more consistent definitions of tobacco use and eliciting information on different types of tobacco consumed.
|How to cite this article:|
Rooban T, Elizabeth J, Umadevi K R, Ranganathan K. Sociodemographic correlates of male chewable smokeless tobacco users in India: A preliminary report of analysis of national family health survey, 2005-2006.Indian J Cancer 2010;47:91-100
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Rooban T, Elizabeth J, Umadevi K R, Ranganathan K. Sociodemographic correlates of male chewable smokeless tobacco users in India: A preliminary report of analysis of national family health survey, 2005-2006. Indian J Cancer [serial online] 2010 [cited 2022 May 20 ];47:91-100
Available from: https://www.indianjcancer.com/text.asp?2010/47/5/91/63865
In India, tobacco consumption is a major risk factor responsible for oral and oropharyngeal cancer. India has one of the highest rates of oral cancer in the world, partly attributed to the high prevalence of tobacco chewing habits.  Nationally representative and reliable prevalence data on chewable tobacco consumption are sparse. Similarly, the sociodemographic predictors of smokeless tobacco are poorly understood. The existing studies on prevalence of smokeless tobacco use are based on nonrepresentative sample surveys or have been conducted primarily for smoking tobacco forms. ,
The nature of chewable areca nut and tobacco consumption in India has undergone a rapid transformation with the introduction of Panmasala and Gutka. These products are conveniently packed and aggressively advertised and marketed. 
Smokeless tobacco consumption, in India, shows a wide variation in different geographical areas and socioeconomic groups. However, barring a few regional studies, very little systematic investigation has been published on socioeconomic and geographic distribution of this habit among males in India. The gaps in our understanding of smokeless tobacco consumption need to be addressed to ascertain which epidemiologic determinants are more likely to result in higher consumption. Such analyses are critical for designing policies and interventions aimed at achieving overall reductions in chewable areca nut and tobacco consumption at the population level and at reducing the inequalities in susceptibility. 
Preliminary reports in India indicate that 36.3% males used smokeless tobacco, whereas only 8.4% of females used them, and there exists a greater disparity in the geographic and socioeconomic distribution of smokeless tobacco use.  Given the paucity of reported exact socioeconomic and geographic prevalence of smokeless tobacco use in India among males, this study was undertaken to estimate the prevalence and socioeconomic and demographic correlates of current chewable tobacco habit among males 15 years and older in India.
Materials and Methods
This secondary analysis of data was done from the Nation Family Health Survey (NFHS) of India conducted during 2005-2006. The data for the study came from the door-to-door survey questionnaire answers for men and women fielded under the NFHS-3-a nationally representative, cross-sectional, household sample survey conducted in 2005-2006. A uniform sample design was adopted in all the states, which has been described earlier. 
In the NFHS-3, information was collected from a nationally representative sample of 74,369 men in the age group of 15-54 years. The NFHS-3 sample covers 99% of India's population living in all the 29 states. The demographic details of the interviewed were categorized.  The present study was performed using the details of 74,369 males obtained from the survey as males tend to use smokeless tobacco more commonly than females  and also considering the fact that sociodemographic determinants of smokeless tobacco use among females will be different. ,
The survey questionnaire had 3 questions addressing self-report on the chewable areca nut and/or tobacco use. They were "Do you currently smoke cigarettes or beedis?," "Do you currently smoke or use tobacco in any other form?," and "In what other form do you currently smoke or use tobacco?" The choices for the last question were cigar/pipe; Panmasala; gutka; other chewing tobacco; and snuff. The answer for the last question was recorded in yes/no format in the database. Use of snuff was not considered as it is not a chewable form of smokeless tobacco.
SPSS version 16.0 (SPSS Inc., Chicago, IL, USA) was used to carry out the statistical analysis. Descriptive variables are presented for demographic variables. The variables for males are presented. Overall prevalence of chewing tobacco and areca nut were computed for various demographic variables as point estimates and 95% confidence intervals are presented by computing the confidence interval around a percent using the statistics calculator (Statpac Incorporation, Version 3, Bloomington, MN, USA). A P value of less than or equal to 0.001 was considered as a significant difference. Binary logistic regression by entering and a simple categoric method was employed to calculate the odds ratio (OR), and 95% confidence interval of the OR are presented.
There were 748 questions in the survey for males. Of all the data analyzed, for certain variables as much as 6.2% did not answer or the data were missing. The number of people with missing data has been included in all the tables.
Of all the male participants, 25,587 (34.42%) used one or another chewing products; 8.1% used panmasala, 11.8% used gutka, and 12.13% used other chewable tobacco products. Among males, use of chewable tobacco was the most prevalent in the age group of 30-34 years, with 40.5% chewing any form of tobacco. The difference was statistically significant (P = 0.000). Thirty-one percent of urban and 38.1% of rural males used chewing substances. The difference was statistically significant (P = 0.000).
As the level of education increased, prevalence of chewing habit decreased. Similarly, as the wealth index increased, the chewing habits decreased across the subgroups among males and females [Figure 1]. This difference was statistically significant (P = 0.000).
State level variation
The prevalence of tobacco chewing varied significantly among different states in India. Regional patterns were observed for chewing panmasala, gutka, and tobacco. Prevalence of chewing tobacco ranged between 57% (Bihar) and 7.2% (Haryana). This difference in the prevalence of tobacco chewing between various Indian states was statistically significant (P = 0.000). Panmasala use was the highest in Orissa (40.8%), gutka in Uttar Pradesh (22.5%), and other chewable products in Assam (51.9%). The difference was statistically significant (P = 0.000) [Table 1] and [Table 2].
Demographic and socioeconomic variables
Chewing of panmasala was more common among the 25-29, 30-34, and 35-39 years age group (each 9.4%) than other age groups (P = 0.000) with an OR of 1.78, 1.79, and 1.79 as compared with the 15-19 years age group. Panmasala was more commonly used by rural males (OR = 1.16) as compared with urban males (P = 0.000). Use of panmasala was highest in migrants or nondejure residents (OR = 1.26) as compared with those in nuclear families. Use of panmasala was higher among ever married (OR = 1.22) than with never married. Among the castes, scheduled tribes used panmasala commonly (17.8%) (P = 0.000) [Table 3].
As the level of education and wealth increased, the prevalence of chewing panmasala decreased. This difference was statistically significant (P = 0.000) [Table 4]. Less use of panmasala was observed in males who read newspaper or magazines, listened to radio or saw television. However, their rates were similar to those who never read, listened to radio, or saw television. This difference was statistically significant (P = 0.000) [Table 5].
Use of panmasala was more common among Christians (21.7%) and low among Parsi (0) and Sikhs (1.1%) (P = 0.000) [Figure 2]. Agricultural employees (9%) and salesmen (9%) more commonly used panmasala. The not working class consumed less of panmasala (5.7%). This difference was statistically significant (P = 0.000) [Table 6].
The use of gutka was more in 20-24 years age group (OR = 1.73) and the difference between age groups was statistically significant (P =0.000). Gutka was popular among people in the urban than the rural areas (OR = 0.93). The difference between the nature and place of residence was statistically significant (P = 0.000). The use of gutka was least common in nuclear families and highest in migrants or nondejure residents (OR = 1.26). As the level of education increased, the prevalence of chewing gutka decreased. This difference was statistically significant (P = 0.000). A low use of gutka was observed among males who read newspaper or magazine, listened to radio or saw television almost daily. Although there was a statistical significance (P = 0.000) between the different levels of exposure to various media, the actual prevalence was similar to those who were never exposed to any media. Use of gutka was common among atheists (42.9%) and low among Jewish (0%), Parsi (0%), and Sikhs (2%). Other products were commonly used by Jews (60%) and less common among Sikhs (12%). The difference between religions was statistically significant (P = 0.000).
The use of gutka decreased as the wealth index increased and this pattern was statistically significant (P = 0.000). The use of gutka was favored by salesmen (13.15%) and least favored by individuals in professional/technical or managerial levels (6.2%), and this difference between professionals was statistically significant (P = 0.000).
The use of other chewable products was highest in 35-39 years age group (26.5%) and lowest in 15-19 years age group (P = 0.000). This habit was widely prevalent among people in rural areas (OR = 1.65), nondejure residents (OR = 1.47), ever married (OR = 2.28), scheduled tribe (OR = 1.53), no education (OR = 1), only primary education (OR =0.93), and among poorest section (OR = 1).
Resultant health information
Panmasala use was highly prevalent in males (9%) with normal body mass index (BMI) and lowest in severely thin (4.7%). Panmasala use was highly prevalent in severe anemic (7.6%) males than not anemic (6.6%). Of all the diabetics, 8.8% chewed panmasala as compared with 8% in nondiabetics. Gutka use was highest among males whose BMI was mildly less (13.9%). Gutka use was highest among severely anemic (13.5%) as compared with 12% of nonanemic persons. The use of other chewable forms was highest in normal BMI males (23.1%) and severely anemic (27.9%) males [Table 7].
To the best of our knowledge, this is one of the few studies to provide nationally representative aggregate prevalence estimates of consumption of different chewing tobacco products related to different socioeconomic and demographic characteristics from the NFHS-3 from India.  This study has dealt with panmasala and gutka, the products that are being increasingly used by Indians. Till date no study has provided a detailed analysis of the prevalence of chewing of panmasala and gutka habit. This present study has an advantage of proper study design and representativeness; however, it also suffers from several data limitations, which could alter the prevalence estimates, including considering only males, absence of details of intensity, frequency, and duration of use. A detailed question on the type of smokeless form of tobacco use has been included in NFHS-3, which has enabled us to do this study. Household informants in this survey may not be aware of the use of tobacco by other household members rather than the individual self-reports and this drawback is in similar studies in the literature that employed earlier NFHS studies.  Hence in the present study, only individual self-reports have been used as per recommendations from earlier studies.  Taking into account all the limitations of the study and the previous literature on the prevalence of tobacco consumption in India, it is safe to conclude that this study provides robust lower bound estimates for the prevalence of chewing tobacco consumption in
India.  Moreover, this study takes into consideration all those who chew panmasala, gutka, or other products individually but does not consider the overlap of the mixed habits. [Figure 3] shows the population aggregate who use chewing tobacco in various forms in the study population. Literature has several reports of smokeless tobacco usage among the locoregional population, , but none on a national or a state level; and hence, the results of this study could not be verified.
State level variation
The chewing tobacco consumption varied significantly across different Indian states. For example, the chewing prevalence was distinctly higher in Central and Eastern India, and in the Northeastern states as reported earlier.  Future studies should be designed to explore the reasons for interstate variation for various products as this can provide important sociocultural dimensional insights that may be essential to design public policies and probable interaction with local sociocultural patterns on the use of tobacco. It has been observed that the use of gutka is greater than panmasala among males at the national level. But in certain North Eastern states, among males, use of panmasala is higher than gutka. There is a distinct pattern in the consumption of types of chewing tobacco emerging across various regions of India, implying the fact that tobacco cessation programs and awareness campaigns have to be modified to suit the locoregional use of these products rather than a mere vernacular translation of nationally used campaigns.
Poverty and illiteracy
Chewing tobacco was the highest in the least educated, poorest, and scheduled castes, and scheduled tribes. This has been demonstrated by the increase in OR. The socioeconomic differentials in chewing tobacco consumption from this study also compared well with the findings from previous studies in India.  The question raised by such studies that why poor and less-educated males consume more chewing tobacco still remains an open empirical question for further investigation and can be partially attributed to the poor level of exposure to the media and awareness campaigns as indicated by this study. Under-reporting of chewing tobacco use by other groups due to social stigma attached with tobacco use in different situations may also have contributed to this trend as reported earlier.  Education emerged as a stronger indicator than wealth and occupation for smokeless tobacco use. It is likely that poor and less-educated Indian males are less aware of the health hazards of tobacco consumption; more likely to find themselves in conditions predisposing them to initiation of chewing tobacco. The findings of the study highlights that an agenda to improve health outcomes for the poor and other similar disadvantaged groups in India must also include effective interventions to control smokeless tobacco use, as these groups suffer from the disproportionate burden of smokeless tobacco-induced diseases. In addition, each intervention should be evaluated for its effectiveness separately in different socioeconomic and cultural groups, since access and effectiveness of different program strategies may vary across these groups.  The effect of smokeless tobacco advertisement ban, pictorial warning on packages, and limiting sales in certain areas, such as educational zones, and the efforts in this regard by the National Rural Health Mission, have to be evaluated in future studies.
Demographics of tobacco consumption
The cross-sectional nature of the data did not permit the assessment of the trends in tobacco consumption over time. The observation of increase in prevalence of chewing tobacco consumption with age has been previously explained as due to a cohort effect (declining prevalence over time with younger cohorts having lower prevalence) or an age effect (younger people having lower prevalence, with more people initiated into tobacco consumption as they get older) or simply due to under-reporting of tobacco use among young people or a higher awareness among younger individuals.  Previous literature suggests no declining trends in tobacco consumption over time in India. The present study portrays a different result for different products. Panmasala and gutka are more popular among younger males, whereas other forms are preferred by the older population. This has been reported earlier by Gupta et al, and discussed in detail.  This has important policy and program implications-the initiation into tobacco use may occur at any age and not just among young people and hence programs to control tobacco have to focus on almost all age groups up to the age of 50 years. The results of the present study are similar to the results of an independent study in Mumbai in the 1990s indicating that education and occupation have important simultaneous and independent relationships with tobacco use that require attention from policymakers and researchers alike. 
A typical Indian male who uses panmasala or gutka is aged below 40 years, from rural parts, is often a non-dejure resident, and is married or separated. He has primary or no education and rarely reads newspaper or listens to radio, whereas he sees television at least once a week. Economically, he belongs to middle to poorer group and often an agricultural employee or a salesman. He has normal BMI and often moderately anemic. He has high chances of having diabetes, asthma, or goiter as compared with nonchewers.
Of the study population, only 17.58% of males reported that they cannot read at all and 26.95% of males were never exposed to print media. Radio was not at all used by 29.28% and television was never seen by 12.46% of them. This proportion was still higher among males who use chewing tobacco. This vital factor should be taken care in designing awareness campaigns. Advertisement stating the ill effects of chewing tobacco products can have a better reach only via people to people or a mass people movement rather than involving any media as at least one eighth of males do to have access or see these campaigns. 
Anemia and diabetes are multifactorial diseases. Areca nut is a known diabetogenic agent and its prolonged use causes increased BMI.  This secondary data analysis fails to highlight a strong association of diabetes-increased BMI to panmasala and gutka use. Although the intensity and duration of habits are vital to arrive at a correlation, due to nonavailability, it was not considered for this study. However, the increased prevalence of severe anemia and diabetes among panmasala and gutka chewers as compared with nonchewing population still remains a cause of concern and requires further investigation.
Sociodemographic details of smokeless tobacco use among representative Indian population are presented. This study for the first time identifies the difference between the prevalence of panmasala, gutka, and other tobacco chewing products. Using results of this study, programs aimed at limiting the spread of smokeless tobacco use can be effectively modified to suit the requirements of local populations. The findings of the study highlight that an agenda to improve health outcomes among the underprivileged in India must include effective interventions to control tobacco use. Failure to do so would most likely result in doubling the burden of diseases-both communicable and noncommunicable among marginalized society. There is a need for periodical surveys using more consistent definitions of tobacco use and eliciting information on different types of tobacco consumed and its long-term effects.
Authors wish to thank Macro International, USA for their kind permission to use the NFHS-3 data specific for this study. We thank Dr. A. Kanagaraj, Chairman and Dr. S. Ramachandran, Principal, of our institution for their support and encouragement.
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