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Estimating the quantity of smokeless tobacco consumption among older adults in India

Open AccessPublished:September 20, 2022DOI:https://doi.org/10.1016/j.cegh.2022.101150

      Abstract

      Problem considered

      Globally, smokeless tobacco (SLT) users are highest in India. Whilst, studies examined prevalence and determinants of SLT use, no evidence exists which examined the quantity of SLT consumed.

      Methods

      Study utilized national representative data from the Longitudinal Aging Study in India (LASI) which adopted a multistage stratified area probability cluster sampling design. First, we computed the average SLT consumption per day (in grams) from the LASI data. Consecutively, we further utilized the projected population approximations from the 26th round of the official United Nations population estimates and prevalence rate of current SLT use from the Global Adult Tobacco Survey (GATS-2) and LASI Survey, separately to estimate SLT use pattern for the entire Indian population aged 45 or above.

      Results

      The prevalence of current SLT use among older adults was 17.2% wherein the SLT use is higher among men (20.8%). On average, an older adult consumes 1.01 g of SLT on a daily basis. The range of SLT quantity consumed by users’ according to the LASI and GATS-2 prevalence, varies from 65,000 kg to 85,000 kg per day whereas, annual consumption ranges from 23 million kilograms to 32 million kilograms, respectively.

      Conclusion

      The development of SLT cessation services examining the quantitative aspects of SLT use would be beneficial in tackling the high SLT burden in India and improving the rates of intention to quit.

      Keywords

      1. Introduction

      Globally, 350 million smokeless tobacco (SLT) users are from 127 countries, whereas 95% of SLT users live in Southeast Asia Region, where India's contribution is highest.
      • Sinha D.N.
      • Suliankatchi R.A.
      • Gupta P.C.
      • et al.
      Global burden of all-cause and cause-specific mortality due to smokeless tobacco use: systematic review and meta-analysis.
      Along with the mass production and availability of varied SLT products in India, SLT products have also yielded popularity owing to the social and cultural acceptability compared to tobacco smoking.
      • Singh S.
      • Jain P.
      • Singh P.K.
      • Reddy K.S.
      • Bhargava B.
      White paper on smokeless tobacco & women's health in India.
      In addition, SLT is also used as a ‘harm reduction’ method to reduce and/or quit tobacco smoking which elucidates the persistent high SLT use in many countries, including India.
      • Suliankatchi R.A.
      • Sinha D.N.
      • Rath R.
      • et al.
      Smokeless tobacco use is “replacing” the smoking epidemic in the South-East Asia region.
      In India, alike many low-income and middle-income countries, data related to current use, frequency of SLT consumption, type of products, SLT use initiation and cessation, is primary by obtained from the Global Adult Tobacco Survey (GATS). However, no information related to the quantity of SLT consumption is obtained from the users in the GATS. While, the extant literature has well-documented the prevalence, determinants and frequency of SLT use, no evidence exists which accentuate on the quantity of SLT consumed. This study examines the amount of SLT being consumed by users aged 45 and older using a nationally representative survey.
      The research evidence on SLT use elucidates that high-level addiction and habit of consuming SLT increases with age especially among the late middle-aged adults posing catastrophic health threats to adult users who are at higher risk of multi-morbidity and mortality as compared to young SLT users.
      • Thakur J.S.
      • Paika R.
      Determinants of smokeless tobacco use in India.
      SLT products contain highly addictive substances such as nicotine and more than 30 carcinogenic elements leading to high-level addiction, periodontal diseases, respiratory and lung impairment, cardiovascular diseases, pre-cancers, cancers (oral, pharyngeal and oesophageal cancers), myocardial infarction, stroke, erectile dysfunction and adverse pregnancy outcomes such as stillbirth and low-birth weight, logged as major harmful effects of SLT use globally.
      • Siddiqi K.
      • Husain S.
      • Vidyasagaran A.
      • Readshaw A.
      • Mishu M.P.
      • Sheikh A.
      Global burden of disease due to smokeless tobacco consumption in adults: an updated analysis of data from 127 countries.
      ,
      • Kakde S.
      • Bhopal R.S.
      • Jones C.M.
      A systematic review on the social context of smokeless tobacco use in the South Asian population: implications for public health.
      Consequently, SLT users are at higher risk of communicable disease namely, novel coronavirus (COVID-19) disease because users use their hands every single time to put the chewing tobacco inside their mouth or cheeks.
      • Kaur J.
      • Rinkoo A.V.
      Public health perspectives of smokeless tobacco and areca nut use in the COVID-19 era.
      In comparison to the combustible tobacco products, the nicotine content in the SLT products is significantly higher which varies between 0.8 and 50.0 mg per gram in India.

      Gupta A, Mehrotra R. Alarmingly High Levels of Nicotine and Carcinogenic Nitrosamines in Smokeless Tobacco Products Sold Worldwide. doi:10.1093/ntr/ntaa184/5909170.

      The sustained use of SLT products which contain high nicotine with addictive properties, results in the early development of nicotine dependence.

      Gupta A, Mehrotra R. Alarmingly High Levels of Nicotine and Carcinogenic Nitrosamines in Smokeless Tobacco Products Sold Worldwide. doi:10.1093/ntr/ntaa184/5909170.

      Approximately, 16.3% males and 6.7% females were highly dependent on SLT use, additionally, high physiological dependence and psychological dependence was observed among users with mean age of 50 years and 56 years respectively.
      • Deolia S.
      • Agarwal S.
      • Chhabra K.G.
      • Daphle G.
      • Sen S.
      • Jaiswal A.
      Physical and psychological dependence of smokeless and smoked tobacco.
      Although, majority of SLT users who desire to quit fail at the preparation stage of tobacco cessation recording the high rates of relapse, explicating the physical dependence and ingrained habit of SLT consumption among the elderly population, leads to hindrance in deliverance of SLT cessation support.
      • Thomas J.L.
      • Ebbert J.O.
      • Patten C.A.
      • Dale L.C.
      • Bronars C.A.
      • Schroeder D.R.
      Measuring nicotine dependence among smokeless tobacco users.
      Therefore, this study aims to examine the quantity of SLT consumed in India by the adult users aged 45 or above during the year 2017-18 utilizing a nationally representative dataset.

      2. Methods

      2.1 Design and settings

      This study analysed the data from the Longitudinal Aging Study in India (LASI), a national representative survey exhibiting the information on health, economic and social well-being of the elderly population of India aged 45 and older based on internationally comparable research design and tools such as Health and Retirement Study (HRS) in the United States and others.
      International Institute for Population Sciences (IIPS)
      NP for, Health Care of Elderly (NPHCE), MoHFW HTHCS of, (USC) PH (HSPH) and the U of SC. Longitudinal Ageing Study in India (LASI) Wave 1, 2017-18, India Report.
      The first wave of LASI conducted in the year 2017-18 provided information about 72,250 individuals, from 36 states and union territories of India.
      International Institute for Population Sciences (IIPS)
      NP for, Health Care of Elderly (NPHCE), MoHFW HTHCS of, (USC) PH (HSPH) and the U of SC. Longitudinal Ageing Study in India (LASI) Wave 1, 2017-18, India Report.
      In order to attain eventual units of observation older adults aged 45 years and above in 36 states and union territories (UTs) of India, a multistage stratified area probability cluster sampling design was adopted in this survey. A three-stage and four-stage sampling design was adopted for the rural and urban areas respectively for each selected state. The first stage consists of Primary Sampling Unit (PSUs) namely Tehsils/Talukas (sub-districts) of each state, whereas the second stage involves the selection of villages and wards from rural and urban areas respectively within the selected PSUs. In the third stage, households were selected from the predetermined villages from both the rural and urban areas of the chosen state. In the case of urban areas, one Census Enumeration Block (CEB) were randomly selected, consecutively the fourth stage of household selection was commenced for the selected CEBs.
      The selection of sub-districts (first stage), villages and wards (second stage) were considered in accordance to Census 2011. The sampling frame of the third stage consists CEBs of each selected ward. Additionally, to obtain the sampling frame for the selection of households from secondary sampling units (SSUs), mapping and listing of household for the each sampled SSUs (i.e. villages in rural areas and CEBs in urban areas) was conducted. Total number of listed households in selected villages/CEBs (SSUs) formed the sampling frame for the selection of households. Additionally, detailed description related to LASI First Wave methodology is publicly available online at https://www.iipsindia.ac.in/sites/default/files/LASI_India_Report_2020_compressed.pdf.
      The individual survey schedule which was available in both English and local language was administered to each consenting respondent age 45 and above and their spouses (irrespective of age) in the sampled households. All eligible participants were provided with information brochures explaining the purpose of the survey, ways of protecting their privacy, and the safety of the health assessments as part of the ethics protocols.

      2.2 Measures

      LASI is the first national-level data which provided the information on the quantity of SLT (in grams) consumed daily or weekly by a current user. In order to enquire about the individual current use of SLT, they were asked: “Do you currently consume any smokeless tobacco products such as chewing tobacco, gutkha, or pan masala?” Those responded in “yes” were considered to be current SLT users. Estimation of the quantity of SLT consumed by an individual was based on the respondents' answer to the survey question, “Please tell me approximately how many grams of smokeless tobacco you normally consume per day? If it is easier, you can tell me how many grams per week”. The response for the SLT consumed in grams was collected for ‘per day’ or ‘per week’ consumption in accordance to the participant recollection.

      2.3 Statistical analysis

      In order to calculate the SLT consumption of the study population, we first computed the average SLT consumption per day (in grams) from the LASI data. However, to extrapolate the SLT use pattern for the entire Indian population (aged 45 years and above) for daily, weekly, monthly and yearly consumption, we utilized the projected population approximations from the 26th round of the official United Nations population estimates
      Economic and Social Affairs D, United nations population division
      World Population Prospects 2019: Methodology of the United Nations Population Estimates and Projections.
      and prevalence rate of current SLT use from Global Adult Tobacco Survey (2016–17) and LASI Survey, separately. To obtain the total quantity of SLT consumption (in grams) for the Indian population (45 years and above), we calculated the average SLT consumption (per kilogram) using the equation mentioned below:
      Avg.SLTConsumption(perkilogram)=((Pst×Pa)×Psc)1,000,000


      where, ‘Avg. SLT consumption’ represents average SLT consumption, followed by Pst and Pa which denotes prevalence of current SLT usage and projected population of India respectively, further, Psc signifies average SLT consumption (in grams) by an individual, information mentioned in the LASI data. All the statistical analysis was conducted using the STATA version 15 software.

      3. Results

      About half of the study population (52.0%) belonged to the age group 45–59 and 53.5% were women (Table 1). 47.0% older population was illiterate and majority lived in rural areas (64.7%). Representation of sample was highest from south region (23.9%), followed by north (18.2%) and east (17.7%) region.
      Table 1Summary statistics of older adults (aged 45 years and above) covered in the Longitudinal Ageing Study in India (LASI), 2017-18.
      Background characteristicsSample distributionPrevalence of smokeless tobaccoSmokeless tobacco quantity consumed per day (in grams)
      n%n%MeanSD
      Age groupp=<0.001p=0.477
      45–491318220.1221216.80.990.09
      50–541091116.6185817.01.051.77
      55–591000515.3173717.41.010.68
      60–641013415.5178017.61.042.02
      65–69884513.5153317.31.000.07
      70–7457468.8102517.80.990.10
      75–7933625.157417.11.072.01
      80+33905.255816.50.980.12
      Sexp=<0.001p=0.412
      Male3048746.5635320.81.021.16
      Female3508853.5492414.01.001.29
      Current marital statusp=<0.001p=0.397
      Currently married4916975.0834117.01.021.40
      Widowed/separated/divorced1557323.7281118.10.990.09
      Never Married8251.312415.00.990.08
      Educationp=<0.001p=0.950
      Illiterate3082447.0564918.31.021.47
      Less than primary748011.4162521.70.990.08
      Completed primary861813.1147717.11.021.23
      Completed secondary1212818.5183315.11.021.11
      Completed high school28054.337713.40.980.11
      Completed college/university25423.92439.60.970.13
      Completed post-graduation & above11761.8736.20.990.06
      Residencep=<0.001p=0.388
      Rural4243064.7852120.11.021.33
      Urban2314535.3275611.91.000.73
      Regionp=<0.001p=0.001
      North region1196618.25534.61.000.05
      Central region890713.6187121.01.112.64
      East region1158217.7355730.70.990.08
      Northeast region851413.0211224.80.960.15
      West region890213.6172819.41.041.34
      South region1570423.914569.31.000.03
      Total655751127717.21.021.21
      The prevalence of current SLT use among adults aged 45 and older was 17.2% (Table 1). Not much variation evident across age groups but 20.8% men consume SLT as against 14.0% among women. SLT use among widowed/divorced/separated women was highest (18.1%), while it was lowest among never married individuals (15.0%). Only 6.2% older population who had completed post-graduate and above level of education consume SLT, while the corresponding percentage was three times (18.3%) and four times (21.7%) higher among illiterate and individuals with below primary school education. Rural residents consume SLT considerably higher (20.1%) as against 11.9% by their urban counterpart. SLT use was highest reported in east region (30.7%), followed by northeast (24.8%) and central region (21%). On an average, older adults consume 1.01 g (Standard Deviation (SD) 1.21) of SLT on daily basis. It varies 1.11 g (SD 2.64) in central region to 0.96 g (SD 0.15) in northeast region.
      We estimated that older adults aged 45 and above consume nearly 65,592 kg of SLT products every day (Table 2). On weekly basis this figure of SLT consumption increased to 4,59,144 kg, and further 19,67,760 kg in a month and 2,39,41,074 kg in a year. Men consume considerably higher quantity of SLT products as compared to women. For instance, SLT consumption was 44,662 kg/day among men, while the corresponding figure was 22,802 kg/per day among women.
      Table 2Estimated quantity of smokeless tobacco use among population 45 and above, India.
      Population (aged 45 years and above)MaleSDFemaleSDTotalSD
      Average SLT consumed (grams per day) - LASI 2017-181.0221.1591.0041.2851.0151.211
      Current SLT Prevalence (in%) - LASI 2017-1827.4614.4520.43
      Current SLT Prevalence (in%) - GATS 2016-1733.322.327.8
      UN Projected Population of India (2016–17)159142500157170000316312500
      Estimates based on LASI prevalence
      Average SLT consumed by current user (in kg) per day446622280265592
      Average SLT consumed by current user (in kg) per week312634159613459144
      Average SLT consumed by current user (in kg) per month13398586840571967760
      Average SLT consumed by current user (in kg) per year16301609832269723941074
      Estimates based on GATS prevalence
      Average SLT consumed by current user (in kg) per day540953512689190
      Average SLT consumed by current user (in kg) per week378667245882624328
      Average SLT consumed by current user (in kg) per month162285810537802675691
      Average SLT consumed by current SLT user (in kg) per year197447751282098532554236
      We found the estimated quantity of SLT products consumption increased when considered prevalence of SLT use based on GATS-2 prevalence among adults aged 45 and above years (Table 2). For instances, nearly 89,190 kg/per day SLT products was consumed among adults 45 and above at national level. This estimates were 6,24,328/week and nearly 3,25,54,236/per year at national level among users.

      4. Discussion

      This study for the first time provides robust estimates on the SLT quantity consumed by the users aged 45 years and older. To the best of our knowledge, there are no extant literature available which explored the quantitative aspects of SLT consumption. In correspondence to the findings, the range of SLT quantity consumed by users (45 years or above) in accordance to the LASI and GATS-2 prevalence, varies from 65.5 thousand kilograms to 89 thousand kilograms for a quotidian use whereas, annual consumption ranges from 23 million kilograms to 32 million kilograms respectively.
      Our findings have several implications. First, the reported notable quantity of SLT consumption by the elderly population aged 45 years or older will result in high nicotine dependency,

      Gupta A, Mehrotra R. Alarmingly High Levels of Nicotine and Carcinogenic Nitrosamines in Smokeless Tobacco Products Sold Worldwide. doi:10.1093/ntr/ntaa184/5909170.

      increasing the frequency of SLT use and rendering their intention to quit. In addition, this cohort will be more prone to the adverse health effects such as oral leukoplakias,
      • Critchley J.A.
      • Unal B.
      Health effects associated with smokeless tobacco: a systematic review.
      cancers
      • Sinha D.N.
      • Abdulkader R.S.
      • Gupta P.C.
      Smokeless tobacco-associated cancers: a systematic review and meta-analysis of Indian studies.
      and metabolic syndrome.
      • Gupta R.
      • Gupta N.
      • Khedar R.S.
      Smokeless tobacco and cardiovascular disease in low and middle income countries.
      Second, the older population is projected to increase in future
      • United Nations
      World Population Ageing.
      will intensify the burden of SLT related diseases, exerting enormous pressure on the overburdened healthcare system of India. The annual economic burden of direct medical cost (129320 INR million) and indirect morbidity and mortality cost (334874 INR million) attributable due to SLT use will proliferate
      • John R.M.
      • Sinha P.
      • Munish V.G.
      • Tullu F.T.
      Economic costs of diseases and deaths attributable to tobacco use in India, 2017-2018.
      affecting users well-being and will also lead to loss in the productivity and economs.
      Third, the widely applied Fagerström Test for Nicotine Dependence (FTND) to determine nicotine dependence among SLT users does not record information related to quantity consumed
      • Ebbert J.O.
      • Patten C.A.
      • Schroeder D.R.
      The Fagerström test for nicotine dependence-smokeless tobacco (FTND-ST).
      like smoking,
      • Kandel D.B.
      • Chen K.
      Extent of Smoking and Nicotine Dependence in the United States: 1991-1993.
      which misapprehend users' nicotine addiction, if their SLT consumption is overall high in a day as compared to their first chew. Hence, this study would enhance the SLT cessation services, providing attention to the quantitative aspect as the timings and frequency of SLT use. In addition, the SLT cessation services in India are dominated by the male users,
      • Singh S.
      • Jain P.
      • Singh P.K.
      • Reddy K.S.
      • Bhargava B.
      White paper on smokeless tobacco & women's health in India.
      that must prioritize and focus on the female users' by developing gender-specific strategies to tackle the high SLT burden among females presented in the study.
      This study has certain limitations. First, we cannot rule out the possibility of SLT use underreporting by older women due to social desirability. Second, the SLT users could have reported the reduced SLT quantities owing to the social desirability, thus difficult to verify. Third, the recorded SLT quantity was based on users’ recollection, so there could be a recall bias. Fourth, there could be many indigenous SLT products that may not be reported in the study owing to the lack of knowledge from both users as well as field investigator side. Fifth, inaccuracy in recording SLT quantities by the field investigators, hence subjected to content errors which cannot be addressed.

      5. Conclusion

      Consumption of SLT products among the older adults will result in high dependency, lower intention to quit tobacco and lower use of existing cessation support. This will adversely impact health of older adults and pose enormous pressure on the overburdened healthcare system. The first-time robust estimates on the SLT quantity consumed by the older adults provided by this study successively creates an opportunity to strengthen and modify the current SLT tobacco cessation services and record the information about the SLT quantity consumed by the users to accurately determine the user's nicotine dependence and improve the chances of SLT-quit attempts.

      Ethics approval

      This study used a LASI Wave 1 data available in the public domain for use by researchers, thus no ethical clearance is required for this study.

      Funding

      No funding was received from any funding agencies in the public, commercial, or not-for-profit sectors to assist with the preparation of this manuscript.

      Patient consent for publication

      Not applicable as no patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

      Declaration of competing interest

      None declared.

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