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Logo of bmjoInstructions for authorsCurrent ToCBMJ Open
BMJ Open. 2012; 2(5): e001348.
Published online Sep 28, 2012. doi:  10.1136/bmjopen-2012-001348
PMCID: PMC3488713
Are socioeconomic disparities in tobacco consumption increasing in India? A repeated cross-sectional multilevel analysis
Nandita Bhan,1 Swati Srivastava,2 Sutapa Agrawal,3 Malavika Subramanyam,4 Christopher Millett,5 Sakthivel Selvaraj,2 and S V Subramanian1
1Department of Society, Human Development and Health, Harvard School of Public Health, Harvard University, Boston, Massachusetts, USA
2Public Health Foundation of India (PHFI), New Delhi, India
3South Asia Network for Chronic Diseases (SANCD), New Delhi, India
4Center for Integrative Approaches to Health Disparities, School of Public Health, University of Michigan, Michigan, USA
5Department of Primary Care and Social Medicine, School of Public Health, Imperial College London, London, UK
Correspondence to Dr S V Subramanian; svsubram/at/
Accepted August 28, 2012.
India bears a significant portion of the global tobacco burden with high prevalence of tobacco use. This study examines the socioeconomic patterning of tobacco use and identifies the changing gender and socioeconomic dynamics in light of the Cigarette Epidemic Model.
Secondary analyses of second and third National Family Health Survey (NFHS) data.
Setting and participants
Data were analysed from 201 219 men and 255 028 women over two survey rounds.
Outcomes and methods
Outcomes included smoking (cigarettes, bidis and pipes/cigar), chewed tobacco (paan masala, gutkha and others) and dual use, examined by education, wealth, living environment and caste. Standardised prevalence and percentage change were estimated. Pooled multilevel models estimated the effect of socioeconomic covariates on the log odds of tobacco use by gender, along with fixed and random parameters.
Among men (2005−2006), gradients in smoking by education (illiterates: 44% vs postgraduates: 15%) and chewing (illiterates: 47% vs postgraduates: 19%) were observed. Inverse gradients were also observed by wealth, living environment and caste. Chewed tobacco use by women showed inverse socioeconomic status (SES) gradients comparing the illiterates (7.4%) versus postgraduates (0.33%), and poorest (17%) versus richest (2%) quintiles. However, proportional increases in smoking were higher among more educated (postgraduates (98%) vs high schooling only (17%)) and chewing among richer (richest quintile (49%) vs poorest quintile (35%)). Among women, higher educated showed larger declines for smoking—90% (postgraduates) versus 12% (illiterates). Younger men (15–24 years) showed increasing tobacco use (smoking: 123% and chewing: 112%). Older women (35–49 years) show higher prevalence of smoking (3.2%) compared to younger women (0.3%).
Indian tobacco use patterns show significant diversions from the Cigarette Epidemic Model—from gender and socioeconomic perspectives. Separate analysis by type is needed to further understand social determinants of tobacco use in India.
Keywords: Public Health, Preventive Medicine, Social Medicine
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