|Year : 2013 | Volume
| Issue : 1 | Page : 29-35
Prevalence of chewable smokeless tobacco in Indian women: Secondary data analysis from national family health survey 2005-06
Thavarajah Rooban, Elizabeth Joshua, Umadevi K Rao, Kannan Ranganathan
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai, India
|Date of Web Publication||13-Mar-2013|
Department of Oral and Maxillofacial Pathology, Ragas Dental College and Hospital, Chennai - 600 119
Source of Support: None, Conflict of Interest: None
Objective: To estimate the nation-wide prevalence of chewable smokeless tobacco consumption among Indian females.
Design: Secondary data taken from cross-sectional nationally representative population-based household survey.
Subjects: 1,24,385 women aged 15-49 years who were sampled in the National Family Health Survey-3(2005-2006). Prevalence of chewable smokeless tobacco consumption was compared with socio-demographic characters.
Materials and Methods: The prevalence of various smokeless tobacco current uses was used as outcome measures. Simple and two-way cross tabulations were the main analytical methods.
Results: Of all the female participants, 13,309 (10.7%) used one or another chewing products; 3.3% used Panmasala, 1.8% used gutka and 6.6%used other chewable tobacco products. 12.8% of women used tobacco in some or the other form and 1.7% smokes tobacco. Smokeless tobacco consumption was more common in poor and less educated. The prevalence of tobacco consumption showed variation with types and varied widely between states and geographical location. This reflects a strong association with an individual'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. The higher use of chewable smokeless tobacco among Indian women is a cause of concern. There is a need for periodical surveys using more consistent definitions of tobacco use and eliciting information on different types of tobacco consumed. Such outcomes will help to frame policies that could curb the increasing use of tobacco in Indian Women.
Keywords: Female, Gutka, India, Panmasala, Smokeless tobacco
|How to cite this article:|
Rooban T, Joshua E, Rao UK, Ranganathan K. Prevalence of chewable smokeless tobacco in Indian women: Secondary data analysis from national family health survey 2005-06. J NTR Univ Health Sci 2013;2:29-35
|How to cite this URL:|
Rooban T, Joshua E, Rao UK, Ranganathan K. Prevalence of chewable smokeless tobacco in Indian women: Secondary data analysis from national family health survey 2005-06. J NTR Univ Health Sci [serial online] 2013 [cited 2020 Apr 7];2:29-35. Available from: http://www.jdrntruhs.org/text.asp?2013/2/1/29/108510
| Introduction|| |
Use of tobacco generates health disparities among different socioeconomic groups and between genders. Women tobacco, besides at risk for health hazard as men, but also face health consequences that are unique to women, including those related to pregnancy and cervical cancer. , Smoking tobacco among women in most high-income countries has increased over the past two decades though there has been a trend of decrease in smoking among men over the same period. The estimated number of women smokers worldwide is about 200 million and projected to be about 500 million within next two decade with current trend. The biggest rise in female smoking is projected to be in the less developed countries. ,,
Tobacco use among women has permeated to all regions of India and all sections of society. It is reported that overall, 2.4% of Indian women smoke and 12% chew tobacco.  The prevalence of smoking among women is low in most areas due to social unacceptability, but is somewhat common in parts of the north, east, northeast India and Andhra Pradesh.  The proportion of women tobacco smokers of all women tobacco users was about 20% in 1993-94, about 25% in 1995-96 and 17% in 1998-99. , Though the prevalence of smoking among Indian women is low at that point of time, it has been warned then, to track it carefully due to the increased marketing efforts and impact of globalization.  The more recent Indian adult tobacco survey 2010, 18.4% of all female above the age of 15 years used smokeless tobacco. However the study failed to differentiate the use of Panmasala and Gutka habit separately. 
The gap in understanding of chewable smokeless tobacco consumption by women needs to be addressed to ascertain which epidemiological determinant 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.  The prevalence of smokeless tobacco use and its socio-demographic determinant of males have been reported earlier.  Given the paucity of such reports among women, this study was undertaken to estimate prevalence of Panmasala and Gutka use among various socioeconomic and demographic categories of Indian women in the age group of 15 to 49 years.
| Materials and Methods|| |
This is a secondary data analysis of the National Family Health Survey (NFHS)-3, conducted by the Mumbai-based International Institute for Population Sciences with assistance from Demographic and Health Surveys (DHS), U.S.A. DHS survey adopts a multi-stage, stratified sample design and specially calculated weights to provide nationally representative estimates. The present survey design was delineated so that all women of India who satisfied the inclusion criteria (15 - 49 yrs of age) had an equal probability of being sampled. Initial target sample sizes were stipulated for each state and each of eight selected cities on the basis of the 2001 Census. The sample size targets had been earlier adjusted considering an HIV research objective. Urban and rural samples were drawn independently in each state. A two-stage cluster sampling procedure was followed in rural areas (villages, households) and a three-stage procedure in urban areas (wards, blocks, households); both included random sampling at the last stage. The data set contained women's responses obtained from 1,24,385 women in the age group of 15-49 years, and samples represented 99 percent of India's population living in 29 states. The response rate was 94.5%. , The demographic details were categorized as per previous reports. ,,
The survey questionnaire included 3 questions addressing self report of tobacco use. They were "Do you currently smoke cigarettes or bidis?", "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; tobacco laced Panmasala; gutka; other chewing tobacco; snuff. The answer for the last question was recorded in yes/no format in the data base. Use of snuff was not considered for this study as it is not a popular chewable form of smokeless tobacco and not commonly used (< 1% of the study population). 
Data from the NFHS-3 are self-weighted at the domain level. To extrapolate the result to general population, sample weights are needed to obtain precise estimates at the national and state level. Since this study targeted only point estimation, the sample weights provided by NFHS-3 were utilized. Demographic characteristics and outcome measures were described using weighted percentages. Percentages were weighted to account for selection probability and non-response using the national women's testing weight for the entire NFHS-3 women's sample. The national level weight was calculated to account for differences in sampling proportions across states and is normalised for the NFHS sample as a whole. Hence, use of the national level weight allows for analyses that produce results representative of the national population and state for state level analysis.
SPSS version 16.0 (SPSS-IBM Inc, IL, USA) was used to carry out statistical analysis. Descriptive variables are presented for demographic variables. Overall prevalence of chewing of smokeless tobacco products were computed for various demographic variables as point estimates and cross-tabulations. 95% confidence intervals are presented by computing the confidence interval around a percent using the statistics calculator (Statpac Incorporation, Version 3, Bloomington, Minnesota, USA). A p value ≤ 0.001 was taken as significant difference.
| Results|| |
Of all the female participants, 10433 (8.4%) used one or another chewing products; 2243(1.8%) used Panmasala, 2268(1.8%) used gutka and 6884(5.5%) used other chewable tobacco products.
Chewing tobacco (any form) was a common practice in Mizoram females 55.3% (45.06-64.14) while lowest in Himachal Pradesh (0%), Punjab 0.2% (0.05-0.36) and Jammu and Kashmir 0.4% (0.05-0.75) in females. The difference was statistically significant. (p ≤0.001) Any chewing tobacco use was common in the older age group of 45 - 49 years (14.6%, 13.93-15.27) and less common in youngest group (3%, 2.81-3.19). (P ≤0.001). Similarly, the rural (9.8%, 9.68-9.92), with no education (13.5%, 13.27 - 13.73) and married and not living together (16.3%, 15.37-17.23) had used more commonly other forms of chewable tobacco.
Panmasala use was highest in Tripura (41.6%, 37.15-46.05), gutka in Odisha (8.1%, 7.34-8.86) and other chewable products in Mizoram (49.1%, 39.52-58.68). The lowest use of Panmasala, Gutka and other forms was in Himachal Pradesh. The difference was statistically significant. (P ≤0.001)
The age group commonly involved in chewing of Panmasala, was the 45-49 years age group (3.6%, 3.25-3.95) whereas chewing of gutka was more in 35-39 years (2.5%, 2.27 - 2.73) and other products was favored by the 45- 49 years age group (10.1%, 9.53-10.67) respectively. The difference was statistically significant. (P ≤0.001) Panmasala, gutka and other products were more commonly used by rural females than their urban counterparts. The difference was statistically significant (P ≤0.001).
Use of Panmasala was more common in primary educated (2.7%, 2.3-2.5) while it was least in those who had completed their higher education (0.5%, 0.36-0.64). This difference was statistically significant. (P ≤0.001) Use of Gutka was commonly observed in person with no education (2.9%, 2.79-3.01) while it was least among those with higher education (0.3%, 0.19-0.41). This difference was statistically significant (P ≤0.001). A similar trend was seen in other forms of chewing tobacco use too.
Use of Panmasala, gutka and other products was higher among those who were married but not living together (widowed/ divorced) than never married or married and habiting together females. The difference was statistically significant (P ≤0.001). Panmasala and other tobacco forms use decreased with increasing wealth index. This pattern was statistically significant (P ≤ 0.001). Occupation wise, service related (2.9%, 2.36-3.44) females more commonly used Panmasala. Gutka was favored by agriculture related (2.4%, 2.25-2.55) and other products were common among skilled and unskilled or manual workers (9.1%, 8.61-9.6). The clerks consumed less of Panmasala (0.7 %, 0.17-1.23)) and Gutka (0.6%, 0.11-1.1) while professional/technical/ managerial consumed less of other products (2%,1.54-2.46). This difference was statistically significant (P ≤0.001) [Table 1], [Table 2] and [Table 3].
|Table 3: Select demographic characteristics and chewing tobacco habits in study population|
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| Discussion|| |
To the best of our knowledge, this is the first study to provide a nationally representative aggregate prevalence estimate of Panmasala use by females of different socioeconomic and demographic characteristics from the Indian NFHS-3. This study for the first time has dealt separately with the use of Panmasala and gutka, the products that are being increasing consumed by Indian females. Till date, only very few national level study has provided a detail analysis or prevalence of chewing of Panmasala and gutka chewing habit among Indian women.  The Indian report global adult tobacco survey, 2009-10 conducted among 35, 529 females, had an overall response rate of 91.8%. The tobacco type had not been delineated to compare the results of the present study.  Owing to this major difference in study methodology, sample design and number, time frame and tobacco definitions, the 2009-10 report could not be used for comparison. However, trend in both studies remain similar.
Detailed question on the type of smokeless form of tobacco use has been included in NFHS-3, has favored us to do this study. The NFHS is a cross-sectional data, which has been collected over different phases involving different persons, although with defined calibration for parameters. The sample size, designs have been considered adequately, though they do not represent India in its entirety. The design of the NFHS-3 did not permit us to consider the frequency, intensity and duration of smokeless tobacco use. The inter-state differences have as with the effect of peer pressures regarding smokeless tobacco use have not also been accounted. Given the limitation of NFHS and secondary data studies and the previous literature on prevalence of tobacco consumption in India, it is logical to conclude that the study could provide a robust lower bound estimates for the prevalence of Panmasala and Gutka among women in India. , The samples weight employed in the study have been used previously in comparable literature. ,
In the time period of 1995 to 1996, the overall prevalence of tobacco use among Indian women has been reported as 2.4% using smoking form and 12% as chewing forms.  Since then, it has been a decade of active media participation in terms of promotion as well as cessation programs of tobacco use. , however the latest 2010 data puts the overall Indian female smokeless tobacco prevalence rate at 18.4% after all adjustments.  The difference in study sample, design and time frame could be the major factors regarding the wide difference in the values.
State level variation
The chewing tobacco consumption among women varied significantly across different states. For example, the chewing prevalence was distinctly higher in the Northeastern states. Future studies should explore the reasons for inter-state differentials for different products as this can provide important insights into effect of different public policies and their interaction with local socio-cultural patterns on use of tobacco. It has been observed that the use of gutka is lesser than Panmasala among women at the national level. But in certain states, such as Chattiagarh, Madhyapradesh, Gujarat and Maharashtra, among females, use of gutka is higher than Panmasala. There is a distinct pattern of type of chewing tobacco emerging across various regions of India, implying the fact that tobacco cessation programs and awareness campaigns has to be modified to loco-regional use of these products rather than a mere vernacular translation of a nationally used campaigns. A similar trend had been observed among Indian males from the same data  as well in more recent data. 
Region-specific differences in female tobacco use practices had been demonstrated in several large population based studies. In seven rural surveys conducted during 1966-69 (Andhra Pradesh, Bihar [two areas], Gujarat and Kerala), in Pune district, Maharashtra and in Goa in 1974, tobacco use prevalence among women aged 15 years and above varied from 15% (Gujarat) to 67% (Andhra Pradesh). , The same trend is too expressed in the present study too. According to NFHS 1998-99 data, regions in order of increasing prevalence of tobacco use among women are the north, south, west, central, east, and the northeast. Chewing tobacco in various states in 1998-99 among women was as follow-up to 61% in Mizoram, 30% to 40% in Orissa and Arunachal Pradesh, 20 to 30% in Meghalaya and Assam, 15 to 20% in Manipur, Sikkim, Nagaland, Madhya Pradesh, Uttar Pradesh, West Bengal and Maharashtra, 10 to 15% in Karnataka, Kerala and Tamil Nadu, 5 to 10% in Andhra Pradesh, Goa, Gujarat, Tripura and Bihar, 2 to 4% in Delhi and Rajasthan and Less than 1% in Punjab, Himachal Pradesh, Haryana, and Jammu and Kashmir.  The region specific trend still persists in recent reports too. 
Demographics of tobacco consumption
As previously reported, the cross sectional nature of the present data did not permit us to study the cumulative trends in tobacco use with age. The observed increase in prevalence of chewing tobacco consumption with age can be 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.  Several literature on female tobacco consumption suggests declining trends  over time in India while there are reports that are contradicting.  This aspects needs further investigation. The socio-economic determinants that influence the use of chewing tobacco needs to identified.
The present study portrays a different result for different products. Panmasala and gutka are more popular among younger females while other forms are preferred by the older population. This implies that programs to control tobacco have to focus on almost all age groups up to the age of 50. It has been reported that the initiation of tobacco use in females may not be limited to childhood and the teenage years.  The present study concurs with the earlier findings. The finding of the present study concurs with earlier findings of women tobacco use is higher in the less educated and poorer social strata.  For occupation, a large study in Delhi, reported that a housewife, a student, or being retired had a protective effect in comparison to being a professional, which is largely reflected in the present study too.  The influence of place of residence, especially coupled with socio-economic status also acquires an important dimension as identified and reported recently among males.  Similar study among females may shed more light on this aspect.
Poverty and illiteracy
Chewing tobacco consumption was the highest in the least educated, poorest, and scheduled castes and scheduled tribes. The socioeconomic differentials in chewing tobacco consumption from this study also compare well with the findings from previous studies.  Under-reporting of chewing tobacco use, social stigma attached with tobacco use in different situation may also have contributed to this trend.  Education emerged as a stronger indicator than wealth and occupation. It is likely that poor and less educated are less aware of the health hazards of tobacco consumption; more likely to find themselves in conditions predisposing them to initiation of smoking and chewing of tobacco; and more likely to have higher degree of fatalism or higher overall risk taking behavior.  The findings of the study reiterates that an agenda to improve health outcomes for the poor and other disadvantaged groups in India must also include effective interventions to control tobacco, as this group may suffer from disproportionate burden of tobacco induced morbidity and mortality. In addition, each intervention should be evaluated for its effectiveness separately in different socioeconomic and cultural groups, since access and effectiveness of different programmatic strategies may vary across these groups as demonstrated by the present study. 
| Conclusions|| |
Demographic details of smokeless tobacco use among representative female Indian population as identified in NFHS-3 are presented. This secondary data study for first time identifies the difference in usage trends between the Panmasala, gutka and other chewing products among various demographic parameters in Indian females. Programs aimed at limiting the spread of smokeless tobacco use among Indian females can be effectively modified to suit the requirements of females as their smokeless tobacco use is definitely different from those of males. Differences in locoregional variation in terms of smokeless tobacco use would help in substantially modifying the nationwide propagandas against smokeless tobacco.
| Acknowledgement|| |
Statistical advice of Mrs. R. Hemalatha is gratefully acknowledged. The authors would like to Macros International for willing to share the data. We would like to thank Dr. S. Ramachandran, Principal, Ragas Dental College and Prof. Dr. A. Kanagaraj, Chairman of Jaya Group of Institution, Chennai for their constant support and encouragement.
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[Table 1], [Table 2], [Table 3]