Patterns and distribution of tobacco consumption in India: cross sectional multilevel evidence from the 1998-9 national family health survey
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.801 (Published 01 April 2004) Cite this as: BMJ 2004;328:801
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The article “Patterns and distribution of tobacco consumption in
India: cross sectional multilevel evidence from the 1998-9 national family
health survey” is interesting and informative however, we would like to
raise certain issues. The National Family Health Survey (NFHS) - 2
collected data from more than 90,000 ever married women between the age
group of 15 - 49 years in India covering all the states. The data on the
consumption pattern of paan masala, tobacco, smoking and alcohol amongst
household members aged 15 years and above was collected. However, no
direct interviews were conducted of the adult male members in the
household (the information was collected by the women interviewed). In
view of the above, there is a strong possibility of under reporting on the
actual scenario possible on pattern of tobacco consumption as the women
interviewed might not be aware of the consumption of tobacco outside the
household. Also due to the social stigma attached with the consumption of
tobacco women might be under reporting to the interviewers. Hence, this
may not be the true reflection of current scenario of the consumption of
tobacco amongst the adult males in India. However, this is the best data
set available on the prevalence of consumption of paan masala, tobacco,
smoking and alcohol in the country.
Competing interests:
None declared
Competing interests: No competing interests
Professor S V Subramanian et al have confirmed in their BMJ study
what we in the field suspected for a long time that tobacco consumption in
the South Asian communities based in the UK reflect what is happing in
their countries of origin. 1, 2
Smoking and tobacco chewing is still a matter of health inequalities
and the strategy adopted by the UK Department of Health in tackling health
inequalities has raised the profile of smoking cessation in addressing
these health inequalities in the South Asian communities 3 South Asian
communities have the highest smoking rates. 4
However, what the Professor and his colleagues have not looked at
intensely is the issue around religion and tobacco use. In the 2001 census
the UK census was the first one of its kind to ask about religion. We are
now finding that Sikh Punjabi’s who had been included within the Indian
category have the lowest tobacco consumption rates both in the UK and in
India on account of a decree set on 13th April 1699 (vaishakahi) in the
Sikh Commonwealth of North India that banned tobacco use through a baptism
ceremony called the Amrit Ceremony. 5 On 13th April 2004 (next week) some
1million Sikhs will refresh their vows not to smoke in this year’s
Vaishaki baptism. The Sikh leaders have taken a strong position against
tobacco and have banned its sale around the Golden Temple Amiritsar.
If the WHO Framework Convention on Tobacco Control Treaty and its
application is handed to the many Indian religious groups like the BJP,
Akali Dal and Shiv Sena then, like the Amrit Ceremony in Punjab, they
could tackle tobacco sale and consumption far quicker than the state. Many
states are still hooked on tobacco taxes to balance budgets and dare not
put bans into place. 6
1) BMJ 2004;328:801-806 (3 April), doi:10.1136/bmj.328.7443.801
2) BMJ 2004;328:780 (3 April), doi:10.1136/bmj.328.7443.780
3) Tackling Health Inequalities: A program for action (2003) Department of
Health
4) Health Survey of England-the health of minority ethnic groups (1999)
DoH
5) McAuliffe, M. A. (1909) Sikh Religion: Its Gurus, Sacred Writings, and
Authors, London, Oxford University Press
6)The World Bank, Washington DC (1999) Curbing the Epidemic: Governments
and the Economic of Tobacco Control
Competing interests:
None declared
Competing interests: No competing interests
It is a little strange that this paper does not mention the
followers of Sikh religion. Although some "Sehjdhari" Sikhs do smoke, no
"Kesdhari" (those with long uncut hair worn under a turban) will smoke -
at least not openly. Aggregating the data for Sikhs, Christians and
Budhists is illogical.
Dr JK Anand
retired public health physician
Competing interests:
None declared
Competing interests: No competing interests
Dear sir, Dr Subramaian et al have done a great job in data
collection,its analysis and publishing the conclusion on this
article,which is a gigantic task in a vast country like India which is
densely populated.We must congratulate the authers for their excellent
work and effort in producing this paper. As it is pointed out ,our country
needs basic education and preventive measures at the national level. The
authers have done the job,it is now the turn of authorities to follow it.
M.S.Basharuthulla MD,FACP,FRCP-Glasg,FRCP-Ire
Ref.Patterns and distribution of tobacco consumption in India:cross
sectional multilevel evidence from
1998-9,national family health survey, BMJ 2004.328 801-806
Competing interests:
None declared
Competing interests: No competing interests
Increasing tobacco consumption among the lower socioeconomic classes in India
Subramanian et al (1) report that tobacco use in more prevalent among
the lower socioeconomic classes in India. In the National Family Health
Survey of India executed in 1998-1999 it is observed that households
belonging to the lowest fifth of standard of living index were 2.54 times
more likely to smoke or chew tobacco than those in the highest fifth. We
studied socioeconomic differences in prevalence of coronary risk factors
and used educational status as its marker. In an Indian rural population
we reported that tobacco consumption (smoking and/or tobacco chewing) was
more 1.59 times more common among the illiterate as compared to those with
more than 10 years of formal education (2). In men (n= 1982), tobacco use
was in 60% illiterate subjects, 51% in 1-5 years of education, 46% in 6-10
years of education and 35.5% in those with more than 10 years of
education. Tobacco use was low in rural women (n=1166) and was 6% in
illiterate as compared to 4% and 2% in other groups. Among urban subjects
also a significant gradient was noted and in men (n=1415), tobacco use was
in 44% illiterate, 52% in those with 1-10 years education, 30% in 11-15
years education and 18% in those with more than 15 years education (3). In
urban women (n=797) tobacco use was confined to the lower socioeconomic
classes only (illiterate 24.1%, 1-10 years education 22.9%).
We performed a repeat survey among the urban subjects to evaluate changes
in coronary risk factors (4). Although there was no change in overall age-
adjusted prevalence of tobacco use in both men (39% vs. 41%) and women
(19% vs. 20%), the use increased significantly among the lower
socioeconomic strata. The tobacco use in illiterate increased from 44% to
54% while it increased from 24% to 28% in illiterate women. A high
prevalence of smoking and other coronary risk factors has been reported
from other parts of India as well (1,5). Clearly the focus of tobacco
control has to be subjects in lower socioeconomic classes in India and
other developing countries. Increasing the educational status of the
population could be one simple approach.
References:
1. Subramanian SV, Nandy S, Kelly M, Gordon D, Davey-Smith G.
Patterns and distribution of tobacco consumption in India: cross sectional
multilevel evidence from the 1998-9 national family health survey. BMJ.
2004; 328:801-806.
2. Gupta R, Gupta VP, Ahluwalia NS. Educational status, coronary
heart disease and coronary risk factor prevalence in a rural population of
India. BMJ. 1994; 309:1332-1336
3. Gupta R, Prakash H, Majumdar S, Sharma SC, Gupta VP. Prevalence of
coronary heart disease and coronary risk factors in an urban population of
Rajasthan. Indian Heart J. 1995; 47:331-338
4. Gupta R, Gupta VP, Sarna M, Prakash H, Rastogi S, Gupta KD. Serial
epidemiological surveys in an urban Indian population demonstrate
increasing coronary risk factor among the lower socioeconomic strata. J
Assoc Physicians Ind. 2003; 55:470-477
5. Misra A, Sharma R, Pandey RM, Khanna N. Adverse profile of dietary
nutrients, anthropometery and lipids in urban slum dwellers of northern
India. Eur J Clin Nutr. 2001; 55:727-734
Competing interests:
None declared
Competing interests: No competing interests