The levels of tobacco use are high at all three strata. We have also observed a significant rural-urban-slum-urban gradient for tobacco use among men as well as women. There are different, and opposing, trends for use of smoked tobacco (more in rural areas) and smokeless tobacco (more in urban area) among men. Among women, the consumption of smokeless tobacco does not vary significantly across the three areas. The trends persist even after adjusting for the effect of potential confounders such as age, gender, literacy status, and occupation of the respondents. To the best of our knowledge, no other community-based study in India has systematically focused on all the three types of residential areas, namely, rural, urban-slum, and urban simultaneously while studying the spatial trend in tobacco consumption. We have adopted a standardized approach to the issue. The results are likely to have a high internal validity with a sufficient number of respondents to study inter-regional differences. Our results should not be interpreted to mean prevalence estimates for Ballabgarh since the results have been standardized against the WHO standard population. The point estimates might not be truly representative of the other northern states of India.
There is a gap in knowledge that exists on the association use of tobacco use with urban-slum residence. Kumar et al
.’s study comes closest in terms of similarity of the population studied. However, they have not provided the exact definitions used for smoking and the data collection study was started over 10 years back. During this period, the definition of smoking too has undergone revisions. And it is very likely that the population characteristics too would have changed.(19
) Reddy et al
. studied non-communicable disease risk factors in industrial populations in highly urban, urban, and periurban areas in India and have come out with findings of much higher prevalence of tobacco use in periurban areas.(28
) NSSO 62nd round (2005-2006) also reports that the proportion of the total household expenditure on tobacco and related products in rural households in India is triple of the consumption in urban households.(29
) The recently conducted NFHS-3 reports that the proportion of male respondents consuming any form of tobacco is 49.9% in urban men and 61.1% in rural men. The prevalence of smoking as reported by the NFHS-3 is higher for rural as compared to urban regions.(10
) The NFHS-3 was conducted in urban-slum populations as well but desegregated data for urban-slums are not yet available.
The use of smoked tobacco by urban-slum respondents is nearer to rural respondents (absolute difference of 4.3%) than the urban respondents (absolute difference of 15.8%). On the other hand, for smokeless forms of tobacco, the urban-slum respondents’ prevalence is much higher than that of the rural respondents (absolute difference of 3.7%) being nearer to the prevalence in urban populations (absolute difference of 1.5%). Simultaneous smoked and smokeless tobacco use was most commonly seen among the urban-slum respondents. The slum population mostly consists of recent migrants from the rural areas and from what we observe, they seem to be rapidly taking up the urban habits while still maintaining their rural habits. The risk of the development of certain disorders such as cancer of the oral cavity is known to be particularly high with the use of smokeless tobacco products. Thus the slum population becomes a highrisk group for the development of diseases associated both with smoked and smokeless forms of tobacco. The burden imposed by these disorders has the potential to further aggravate the already poor health status of these populations.
The most common form of tobacco being consumed in all the three populations in our study is bidi
. The high prevalence of bidi use and smokeless tobacco use is seen among the rural and urban-slum respondents. The mean number of bidis smoked too was highest in these populations. These population groups also have a higher proportion of respondents who are poorly educated and are unemployed or engaged in lower paying jobs. These findings are supported by observations of Jindal et al
. and Chaudhary et al
. in rural as well as urban settings and by Chhabra et al
. and Gupta et al
. in urban settings.(30
) Narayan et al
. however had reported a higher proportion cigarette use compared to bidi use in urban population of Delhi.(34
) A very likely reason for this observation is the pricing strategy of these tobacco products. Bidis cost nearly one-tenth of the cost of cigarettes. Gutkha and khaini, the two common smokeless tobacco products, are available for as little as half a rupee (approximately $0.01).
The prevalence of hookah use is high in the villages where it is the second most common form of tobacco used. The use of hookah is almost equally common among rural men and women. Hookah smoking is a habit that has been associated with Indian villages for several centuries. Over the years, the use of bidis and hookah has come to be very much ingrained in the rural villages of north India. It has become customary to offer bidis or hookah to visitors. Their ease of availability in the rural households is a likely reason for their predominance seen among rural women. The proportion of smokeless tobacco use is lower than smoking among women in all three regions. The pattern of tobacco consumption in women is known to show regional variations and the same could be the reason for our current observations. Our results also lend support to the general consensus that the mean age of initiation of smoking has been coming down. However, this result is subject to recall bias particularly for older age groups.(35
) The observation of a high odds ratio of current daily tobacco use among illiterate men compared with higher secondary school educated males is supported by results published by the NFHS-3, Narayan et al
., Gupta et al
., and Subramanianet al
) The pattern that we observe is similar for all types of tobacco use except for cigarettes, where the odds of being a current cigarette smoker are higher among higher educated categories (even though this result is not significant in our study).
India is a signatory to the Framework Convention on Tobacco Control (FCTC) since September 2003. The Indian parliament has passed “The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act” in 2003 (CTPA) and it was enforced from May 1, 2004. This Act calls for a ban on the sale of tobacco products to minors, a ban on direct and surrogate tobacco advertising (except at point of sale and on tobacco packs), and prohibition of smoking at public places. Even though the Indian Act is an important landmark step forward, there are still a few missing issues that need to be addressed as per the FCTC. Further, the implementation of the act has been lax as has been noted by Sinha et al
. who found high levels of exposure to tobacco advertising by billboards among adolescents.(38
) Further, there have been reports of use of pan masala (mixture or areca nut, slaked lime, catechu, and condiments) advertisements as surrogates for smokeless tobacco products especially gutkha.(39
) Irregularities in the implementation of point-of-sale tobacco advertisements have also been reported.(40
) A recent monograph notes that bidis are widely available in the remotest of Indian villages, branding is such that they strike a chord with the masses, and because the bidi-manufacturing industry is viewed as small scale, the current policies also seem to favor the bidi industry.(41
) The issue of hookah smoking also does not figure in the current policies.
In light of the existing evidence and the results of the present study, it is clear that the tobacco control policy in India is not geared adequately toward addressing the issue and there is a need to modify the CTPA and widen its ambit. What our study stresses is the need to have rural orientation in the National Tobacco Control Programme that is currently being developed by the Government of India. There is also a need to focus on urban-slums as they are emerging as high-risk groups having a high prevalence of tobacco use. Our study reinforces the notion that bidis are the main tobacco product being consumed and as such the existing policies which favor the bidi industry need revision. Since the poorly educated individuals living in urbanslums and rural areas are at the maximum risk of using tobacco, identifying ways and means of reaching out to these communities will be critical to the success or failure of the program.