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Indian Journal of Community Medicine

Epidemiological Determinants of Tobacco Use In Gujarat State, India

Author(s): DV Bala, ILA N Bodiwala, DD Patel, PM Shah

Vol. 31, No. 3 (2006-07 - 2006-09)

Introduction

Despite high predominance of tobacco related cancers in Gujarat (52% in men and 16% in women), there is a paucity of prevalence studies in the community1. Therefore, a baseline Knowledge, Attitude and Practice (KAP) survey of 80,157 subject, on Cancer Awareness and Prevalence of different habits, was conducted in the community in four districts of Gujarat viz. Panchmahals, Banaskantha, Bharuch and Kheda. Each of these four districts was individually surveyed with a sample of 20,000 subjects and, separate reports were prepared. Information was disseminated to the government for making health policy decisions and feedback was given to the public through health infrastructure and media for curbing these habits. The objectives of the study were to study prevalence of tobacco use and identify its various determinants and application of this study to control this addiction (vice) in the community as a part of evaluation of the National Cancer Control Programme. (NCCP).

Material and Method

Total population of these four districts is about 8 million2. A total of 80,157 adults (47831 male and 32326 females) belonging to age≥18 years were interviewed in person by trained fieldworkers. This sample was drawn by multistage simple random sampling technique by probability proportion to size sample from 800 villages in four districts. Local graduates were trained in the subject from the point of cancer and habits and were employed as field workers for collection of data from the population. Respondents in each village or town were identified and interviewed in person. The investigators monitored 10% sample for accuracy and validity of data. Each of these four districts was individually surveyed with a sample of 20,000 subjects in each and separate reports were prepared. Since there is not much variation in the study among four districts, all (80,157 subjects) data is combined and results are reported together.

Tobacco use definitions and criteria were based on standard WHO guidelines. All tobacco consumption was broadly classified into four categories: smoking, chewing snuffing, and more than one form of tobacco use.

Socio-demographic variables included age, education, occupation and caste. Since the data about income from such a large sample was not uniformly reliable, especially where majority (approximately 85% – 92%) of the studied population was rural, income has not been considered in analysis.

Results

Amongst various addictions, tobacco was the most popular and highest recorded addiction. Candid response to alcohol consumption is difficult to obtain in the dry state of Gujarat state with legal prohibition on the sale of alcohol. Therefore its reported prevalence as expected, was relatively low. Similarly, combination of these two addictions (tobacco and alcohol) was also less. Tobacco free pan-masala is relatively a new habit and more common in urban areas and elite population. As this survey has been conducted in four under developed districts with large rural and considerable scheduled tribe population, it is observed that pan- masala use is the least prevalent in this study. Thus, alcohol and pan-masala were relatively unimportant in this population, only tobacco addiction has been focused.

Table I: Gender Wise Distribution of Various Addictions

Habits Male (%) Female (%)
Alcohol 13.41 2.62
Alcohol + Tobacco 11.31 1.20
Pan-Masala 4.35 1.17
Tobacco 61.89 26.46

Overall current prevalence of tobacco in different forms was 47.6% in the total population in Gujarat. The prevalence was 61.89% in men and 26.46% in women. It is observed that tobacco use in the community increased with increasing age.

Its prevalence was high in illiterate and in literates with less than seven years of schooling, but decreased significantly with increase in education status after attaining secondary education and more. In the occupational groups, agriculture and labour class had the highest prevalence as compared to other groups.

In the schedule tribe (ST) population, tobacco use was found to be comparatively higher than other castes and it was least in privileged class. The differences in different groups in all above socio-demographic variables were highly significant (P < 0.001)

Table II: Distribution of Various Habits by Age, Education, Occupation and Caste

  Variable Tobacco %
Age Groups (Years) ≤ 25 33.19
  26-35 43.31
36-45 51.90
56-65 59.34
> 65 56.01
Education Illiterate 50.60
  Literate 53.41
Primary 53.51
Secondary 40.84
Higher Secondary 29.92
Graduation & above 24.83
Occupation Household 21.27
  Unemployed 35.86
Agriculture 59.35
Labour 59.88
Business 49.66
Service 40.77
Caste Privileged 43.76
  Schedule Caste + S.E.B.C.* 48.97
Schedule Tribe 50.74

S.E.B.C. = Socio Economically Backward Caste

(Proportion computed from the total number of respondents in each Age, Education, Occupation and Caste Group)

Table III: Distribution of Various Forms of Tobacco Use in Men and Women

Forms of Tobacco Male (%) Female (%)
Smoking 81.11 33.91
Chewing 15.80 25.86
Snuffing 1.26 38.98
More than one form 1.85 1.20

Smoking was the commonest form accounting for 81.1% of total male tobacco users but snuffing was the major form of tobacco use in nearly 39% female users. The prevalence smoking and chewing in women were 33.9% and 25.86% respectively. As compared to men (15.8%) chewing form of tobacco (as khaini, mawa or tobacco dentifrice) was proportionately more common in women (25.86%). Similarly, snuffing was also predominantly a practice of women. The gender differences in the use of tobacco in its various forms was statistically highly significant (P < 0.001).

Smoking was also the most frequent form of tobacco use in any age, education or occupation group except in household occupation. Subjects with low literacy, agriculture and labour occupational groups had a significantly higher prevalence of smoking (P < 0.001). Chewing (commonest smokeless tobacco) was highest in subjects below 25 years of age and those with higher secondary education and also those in business or service. Thus, chewing was observed to have direct and positive association with education but negative association with age. Snuffing was highest in the women, the elderly, illiterate group and in householders occupation consisting of women. This practice decreased drastically with increasing level of education, in business and service class.

Table IV Different Forms of Tobacco use by Age, Education and Occupation

  Variable Smoking Chewing Snuffing >One Form
(%) (%) (%) (%)
Age Groups ≤ 25 59.51 33.19 5.80 1.43
  26-35 71.56 17.80 9.49 0.96
36-45 73.30 12.68 12.74 0.91
46-55 74.58 10.31 13.47 1.17
56-65 71.23 9.70 16.56 1.57
> 65 64.73 10.68 20.36 1.90
Education Illiterate 68.44 9.94 19.28 0.77
  Literate 75.69 15.62 5.31 2.17
Primary 79.74 13.94 4.05 1.27
Secondary 64.99 29.43 1.89 1.61
Higher Secondary 54.85 43.71 2.11 2.40
Graduation (Plus) 38.81 65.39 2.45 2.68
Occupation Household 25.56 22.18 51.59 0.93
  Unemployed 53.43 33.70 9.45 2.88
Agriculture 78.67 11.66 7.91 0.97
Labour 79.14 11.18 8.20 1.05
Business 65.66 28.81 3.48 1.61
Service 63.48 33.36 1.62 1.71

(Proportion computed from the total tobacco users in each Age, Education and Occupation Group)

Table V: Age at which Tobacco use was Started Sex wise Distribution

5-10 YR 11-15 YR 16-20 YR 21-30 YR 31-50YR > 50
5.6 16.07 9.05 20.05 15.57 16.7
0.44 4.2 11.03 19.55 29.35 25.26

(Proportions computed from total number of Tobacco users in each group.)

(Proportions in each group do not add upto 100% as some could not recall the age at which tobacco use was started)

In order to know the time trends in the age of initiation of tobacco in this population age -wise distribution of all tobacco users was studied. It is disheartening to find that the youngest subjects in the studied population (currently under 25 years of age) had started the habit relatively early in the childhood as compared to the subjects over the age of 25.

It is observed that tobacco started from a very early age (5-10 years of age) in either sex, initially as an occasional use, subsequently becomes addiction. However, this is more pronounced in males in comparison to women. As many as 40.7% of men as against 16% of women, started the use of tobacco below 20 years of age and soon get addicted to it. While maximum proportion of tobacco consumers amongst women (74%) adopted after the age of twenty. Over half of the women tobacco users first began its use after 31 years of age. The peak of initiation of tobacco consumption was observed between 21 and 30 years in both sexes.

Table VI: Age Wise Distribution of All Studied Subjects By Age At Which Tobacco Use Was Started

  0-25Y 26-35 Y 36-45Y 46-55Y 56-65 Y A 65
5-10Y 9.16 5.22 4.22 5.1 1.2 0.55
11-15Y 34.7 21.71 11.68 7.58 7.14 7.3
16-20Y 30.17 23.18 18.02 9.66 13.64 14.62
21-30Y 14.33 30.07 25.38 21.79 12.26 10.47
31-50Y 0 7.27 17.19 36.45 35.92 28.63
>51Y 0 0 0 10.04 18.32 20.71

(Proportions computed from total number of Tobacco users in each group.)

(Proportions in each group do not add upto 100% as some could not recall the age at which totacco use was started)

Strikingly, about three fourths of the youth who were below 25 years of age at present initiated into this addiction relatively early in the childhood, before they were even twenty years.

Thus about 9% of these young adults first started between 5 and 10 years of age, another one third of them picked up in their early teens. Some 30% started in their late teens. The peak age group of starting this addiction in those presently between 25 and 35 years of age (a decade older) was 21 - 30 years. About 30% of them started after 20 years of age, even though over 50% of them started below twenty years of age. In adults a decade older than these subjects (i.e. over 35 years of age currently) over one-third of the tobacco users started before they were 20.

Majority of all the tobacco consumers over 45 years of age relatively started its use at a later age. The proportion of subjects who initiated tobacco use below 20 years of age was observed to be about 22% in those currently older than 45 years of age. About half of all the subjects in all educational groups except higher secondary educated tobacco users had started early i.e. below 20 years of age. Similarly, over 40% of all tobacco consumers belonging to the occupation of agriculture, or labourers started tobacco consumption before the age of twenty.

Half of all men and one third of women started tobacco use by imitating peer groups. Some took up this habit either to decrease fatigue and mental tension or to relax. About 6.37% and 3% of total respondents were ex – tobacco users. Majority of them (95%) gave up their habit for health reasons and the rest for economic reasons.

Discussion

It is clear from this cross sectional study that tobacco consumption is highly prevalent in predominantly rural Gujarat. While it is smoking followed by chewing in men; it is snuffing, smoking and chewing in women as the norm. In the study of tobacco habits in India by Bhonsle, et al the overall prevalence rates among men varied from 61% in Maharashtra to 86% in Andhra Pradesh; among women it ranged from 15% in Bhavnagar (Gujarat) to 67% in Andhra Pradesh.3 Men preferred smoking and chewing and women chewing with some regional variations in their study. Our study is comparable to this.

In the study of tobacco use in rural area of Bihar, India, by Sinha, etal tobacco use was 78% in men and 52% among women.4 Current smoking pattern was largely bidi and smokeless tobacco users used mostly dentifrice. These are similar to our study as well.

In our study, subjects with low literacy, agriculture and labour occupational groups had a significantly higher prevalence of smoking. While smoking was significantly directly associated with increasing age, it showed an inverse relationship to increasing levels of education, privileged class and service and business by occupation. In contrast, chewing was observed to have direct and positive association with education but negative association with age. Snuffing was highest in the women, the elderly, illiterate group and in householders occupation consisting of women. This practice decreased drastically with increasing level of education, in business and service class. Chewing was highest in subjects below 25 years of age and those with higher secondary education and also those in business or service.

It is known from this study that more and more youngsters are falling a prey to the tobacco products and, they are also attracted to smokeless form by the advertising and marketing agencies. The matter of serious concern is that the age at initiation of tobacco products has considerably reduced. The largest proportion (74%) of tobacco consuming youngsters currently under 25 and further 50% in the 26-35 years age group have initiated tobacco use in childhood or in adolescence. Majority of the middle aged and elderly adopted at a later age. Thus exposure to tobacco from an early age would risk the development of pre-malignant and malignant lesions of upper aero-digestive tract A limitation of this study is that even though the study population is predominantly rural, the analysis could not be done by this variable.

Conclusions and Recommendations

It is evident from this study that younger subjects have started tobacco use relatively at an early age. Therefore, prevention strategies (anti-tobacco education) should be initiated right from the beginning of the primary school. Currently tobacco free pan-masala and tobacco incorporated pan-masala is in vogue in high school and college students, especially in urban areas. This is also accepted as an innocuous habit. Traditionally, use of snuff has been considered a safe form of tobacco use and is also culturally acceptable form of tobacco addiction. Therefore it has been largely practiced by rural women in particular. We have to fight the established acceptance of these addictions by the family and community.

The scientific data on the harmful effects of tobacco should guide the government to enforce the existing legislation rigorously and the vested interest of the multinational companies be opposed by the government to if tobacco pandemic is to be avoided.

Acknowledgement

This study was conducted under the aegis of National Cancer Control Programme and Overseas Development Administration of U.K. The authors also thank Mr. Ronak Patel and Ms. Priti Pandey for their assistance in statistical analysis of data.

References

  1. Annual Report of Population based Cancer Registry of Ahmedabad Urban Agglomeration Area and Hospital based Cancer Registry of Gujarat Cancer Research Institute, 1997.
  2. District Census reports of four districts (Panchmahals, Banaskantha, Bharuch, Kheda) 1991 census.
  3. Bhonsl RP, Murti PR, and Gupta PC (1990) Tobacco habits in India in the Control of Tobacco-related Cancers and other diseases Proceedings of International Symposium, January 1990, TIFR, Bombay. Page 25-46.
  4. Sinha D, Gupta PC and Pednekar M. Tobacco use in rural area of Bihar, India, IJCM 2003; 28 : 167-70.

Deptt. of Community Oncology, Gujarat Cancer and Research
Institute, Ahmedabad, Gujarat.

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