Edited by: Ruwan Jayasinghe, University of Peradeniya, Sri Lanka
Reviewed by: Arvind Muthukrishnan, Saveetha Dental College and Hospitals, India; Nilantha Ratnayake, Governement of Sri Lanka, Sri Lanka; Hemantha Amarasinghe, Ministry of Health, Nutrition and Indigenous Medicine, Sri Lanka
This article was submitted to Life-Course Epidemiology and Social Inequalities in Health, a section of the journal Frontiers in Public Health
†These authors have contributed equally to this work
‡ORCID: Ritik Agrawal
Shishirendu Ghosal
Jogesh Murmu
Abhinav Sinha
Srikanta Kanungo
Sanghamitra Pati
This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
Evidence on smokeless tobacco use is scarce among indigenous communities, with the available literature based either on a specific tribe or on a particular region. Therefore, we aimed to estimate the prevalence of smokeless tobacco and assess its correlation among tribal communities in India.
We utilized data from the Global Adult Tobacco Survey-2 conducted in 2016–2017. A total of 12,854 tribal people aged >15 years were included in this study. The utilization of smokeless tobacco was estimated using the weighted proportion, and its correlates were assessed by multivariable logistic regression reported as an adjusted odds ratio (AOR) with a 95% confidence interval.
The prevalence of smokeless tobacco use was 32%. Participants aged 31–45 years [AOR: 1.66 (1.37–2.00)], who were men [AOR: 2.37 (1.94–1.90)], and who were daily wage/casual laborers [AOR: 5.32 (3.39–8.34)] were observed to have a significant association with smokeless tobacco. Willingness and attempt to quit smokeless tobacco were higher in Eastern India (31.2%) and central India (33.6%), respectively.
We observed one-third of the tribal individuals used smokeless tobacco in India. Tobacco control policies should prioritize men, rural residents, and individuals with fewer years of schooling. Culturally appropriate and linguistically tailored messages are required for behavioral change communication.
The tobacco products used without combustion through chewing, snuffing, spitting, applying on teeth and gums, and dipping are known as smokeless tobacco (SLT) (
The prevalence of SLT consumption (21.4%) is double that of smoking (10.7%) in India, which necessitates the need for investigating the burden of smokeless tobacco and its determinants (
Although existing tobacco control programs such as the National Tobacco Control Programme (NTCP) have helped in reducing the SLT burden, there is a need to monitor the current status of tobacco use among tribal communities since they are more vulnerable to its use. The majority of the evidence on SLT use among tribes stems from a localized region or is based on a survey of a specific tribe, with no nationally representative study. Keeping in view the vast tribal population of India and their distinct health-related behaviors, it is critical to develop evidence on SLT use in this community. Hence, we aimed to estimate the prevalence of smokeless tobacco including different types of SLTs, and determine its correlates and the regional variations among tribal people in India using nationally representative data from GATS-2, 2016–2017.
We employed data from the second edition of the Global Adult Tobacco Survey (GATS) conducted during 2016–2017 in India. GATS is a nationwide cross-sectional survey of a representative adult population aged ≥15 years. It employed a standard methodology to collect community-based data on tobacco use and its control indicators. Approximately 74,037 participants were surveyed during GATS 2 across 30 states and two union territories of India using a multi-stage cluster sampling method. To reach the final unit of sampling, three-stage and two-stage sampling designs were employed in urban and rural areas, respectively.
The eligibility of each household member was determined by administering the household questionnaire. One adult was randomly chosen from a list of all eligible adult occupants of the household to complete an individual questionnaire. The detailed methodology for GATS-2 can be referred to elsewhere (
In this study, we included tribal people aged ≥15 years who were interviewed during the GATS-2 survey. GATS-2 enquired about the ethnicity of the participants based on the question “Do you belong to a scheduled caste, scheduled tribe, other backward castes, or none of these groups?” The participants who responded their caste to as “scheduled tribe” were included in this study. Out of 74,037 individuals surveyed, 12,854 participants belonged to the scheduled tribe (ST) community forming the ultimate sample size.
The main variable of interest was SLT users, which were formed on the basis of the question “Do you currently use smokeless tobacco on a daily basis, less than daily, or not at all?” Those who responded to their SLT use status to be “daily” or “less than daily” were considered SLT users, while those who answered as “not at all” were grouped as SLT non-users.
We classified age, a continuous variable, into four categories: 15–30 years, 31–45 years, 46–60 years, and ≥61 years. Gender was recorded as male and female. The residence of the participants was grouped as rural and urban. Based on the geographical location, Indian states were grouped into six regions, namely, east, west, north, south, central, and northeast. Education of the respondents was classified into five groups, namely, no formal schooling, primary incomplete, primary but not secondary, secondary and higher, and graduation and above. Occupation of the participants described their current working status with groups being government and non-government employees, self-employed, unemployed, homemaker, daily wage/casual laborer, and student. The wealth index was calculated by reducing the dimensions of 14 household assets employing principal component analysis (PCA). The scores obtained were stratified into 5 quintiles with the lowest score as denoting poverty, the highest score denoting wealth, and the middle three scores clubbed together as the middle class. Smoking status was grouped as smokers and non-smokers. Participants who responded that they want to quit SLT were termed as willing to quit, while those who tried to quit tobacco in the last 12 months were grouped as ‘attempted to quit'. A detailed description of each variable is provided in
STATA version 17.0 (STATA Corp., Texas) was used for analysis. We used mean and standard deviation to report the age of participants along with the age of SLT initiation. The prevalence of SLT among various sociodemographic characteristics was reported as frequency and proportion (%). Patterns of various SLT consumption were estimated through a simple matrix approach, which was presented for all possible combinations of SLT products (
There is no risk to the participants because the current study is based on secondary, anonymized GATS-2 data. The original GATS survey administered informed written consent to all the respondents before participation.
The mean age of participants was calculated to be 37.7 (±14.9) years, with more than two-thirds of the population aged between 15 and 45 years. Approximately one-fifth of the population (21.3%) were urban residents, and the gender proportion was marginally skewed toward women (54.38%). The prevalence of SLT use among the tribal population was 32.2% (95% CI: 31.32–33.00). The mean age of initiation of SLT use was observed to be approximately 20.7±8.1 years. We observed that approximately 9% of the SLT users were younger than 21 years of age.
Among the tobacco products, “khaini or tobacco lime mixture” was the most frequently [16.0% (95% CI: 15.4–16.7)] used, followed by “gutkha/tobacco lime and areca nut mixture” [7.3% (95% CI: 6.8–7.8)] and “oral tobacco, snuff, gul, and gudakhu” [7.1% (95% CI: 6.7–7.6)]. Khaini along with gutkha was the most widely used combination [5.55% (95% CI: 4.79–6.37)], followed by khaini and gul [3.71% (95% CI: 3.09–4.41)], among our target population. A prevalence of 1.53% (95% CI: 1.13–2.00) was even accounted for consuming all the major SLT products (i.e., khaini, betel, gutkha, gul, paan, and snuff). A detailed description of commonly used SLT products is presented in
Weighted prevalence of different types of smokeless tobacco use (
| Betel quid with tobacco product | 463, 3.82% (3.48–4.17) |
| Khaini or tobacco lime mixture | 1,940, 16.00% (15.35–16.66) |
| Gutkha /tobacco lime, areca nut mixture | 884, 7.29% (6.83–7.77) |
| Oral tobacco, such as snuff and gul gudakhu | 862, 7.11% (6.66–7.58) |
| Pan masala and betel quid without tobacco | 261, 2.15% (1.90–2.43) |
| Nasal use of snuff | 103, 0.85% (0.69–1.03) |
| Others | 56, 0.46% (0.35–0.60) |
| Khaini + Gutkha | 185, 5.55% (4.79–6.37) |
| Khaini + Gul | 124, 3.71% (3.09–4.41) |
| Khaini + Betel | 55, 1.64% (1.24–2.14) |
| Khaini + Betel + Gutkha + Gul + Paan + Snuff | 51, 1.53% (1.13–2.00) |
| Gul + Gutkha | 43, 1.27% (0.93–1.73) |
| Khaini + Paan | 42, 1.26% (0.91–1.70) |
| Gul + Gutkha + Khaini | 40, 1.20% (0.86–1.63) |
The highest prevalence of SLT use was recorded among the 31–45 years age group [39.7% (95% CI: 38.1–41.4)]. Smokeless tobacco use was higher among men (41.63%) than women (22.84%). We observed a significant proportion of the participants with no formal education [35.5% (95% CI: 34.0–36.9)], incomplete primary education [38.7% (95% CI: 36.1–41.4)], and incomplete secondary education [37.6% (95% CI: 36.0–39.3)] were smokeless tobacco users. Smokeless tobacco use was most prevalent among the tribal people from the eastern part [42.3% (95% CI: 40.5–44.0)] of India. Smokeless tobacco use in other regions, such as Northeast India [35.0% (95% CI: 32.4–37.5)] and central India [36.2% (95% CI: 34.6–37.9)], was also high. With an increase in the wealth index, a gradual decrease in the use of SLT products was observed (
Distribution of sociodemographic characteristics across SLT users in GATS-2.
| Age (years) ( |
15–30 | 5,396, 44.50% | 1,324, 24.5% (23.4–25.7) |
| 31–45 | 3,506, 28.91% | 1,393, 39.7% (38.1–41.4) | |
| 46–60 | 2,118, 17.46% | 790, 37.3% (35.2–39.4) | |
| >60 | 1,108, 9.13% | 392, 35.4% (32.6–38.3) | |
| Gender ( |
Male | 6,007, 49.53% | 2,501, 41.63% (40.4–42.9) |
| Female | 6,121, 50.47% | 1,398, 22.84% (21.8–23.9) | |
| Residence ( |
Urban | 2,013, 16.60% | 502, 24.9% (23.0–26.8) |
| Rural | 10,115, 83.40% | 3,397, 33.6% (32.6–34.5) | |
| Region ( |
North | 182, 1.50% | 8, 4.4% (1.9–8.5) |
| Central | 3,324, 27.41% | 1,204, 36.2% (34.6–37.9) | |
| East | 3,203, 26.41% | 1,354, 42.3% (40.5–44.0) | |
| Northeast | 1,384, 11.41% | 484, 35.0% (32.4–37.5) | |
| West | 2,139, 17.63% | 550, 25.7% (23.9–27.6) | |
| South | 1,896, 15.63% | 299, 15.8% (14.1–17.5) | |
| Educational qualification ( |
No formal education | 4,506, 37.19% | 1,598, 35.5% (34.0–36.9) |
| Primary incomplete | 1,353, 11.17% | 524, 38.7% (36.1–41.4) | |
| Primary but not secondary | 3,379, 27.89% | 1,271, 37.6% (36.0–39.3) | |
| Secondary and higher secondary | 2,218, 18.31% | 419, 18.9% (17.3–20.6) | |
| Graduation and above | 658, 5.43% | 82, 12.4% (10.0–15.2) | |
| Occupation ( |
Govt. and NON–GOVT. EMployee | 839, 6.92% | 246, 29.3% (26.2–32.5) |
| Daily wage/Casual laborer | 3,992, 32.93% | 1,726, 43.2% (41.7–44.8) | |
| Self–employed | 2,410, 19.89% | 1,005, 41.7% (39.7–43.7) | |
| Homemaker | 3,042, 25.10% | 584, 19.2% (17.8–20.6) | |
| Unemployed | 712, 5.88% | 242, 34.0% (30.5–37.6) | |
| Student | 1,125, 9.28% | 96, 8.5% (6.9–10.3) | |
| Wealth index ( |
Poor class | 4,692, 39.03% | 1,663, 35.4% (34.1–36.8) |
| Middle class | 5,956, 49.55% | 1,929, 32.4% (31.2–33.6) | |
| Rich class | 1372, 11.41% | 269, 19.7% (17.5–21.8) | |
| Smoking tobacco ( |
Yes | 1,542, 12.71% | 536, 34.8% (32.4–37.2) |
| No | 10,586, 87.29% | 3,363, 31.8% (30.9–32.7) |
The highest chances of SLT use were observed to be among participants aged 31–45 years [AOR: 1.66 (1.37–2.00)] as compared with the respondents aged 15–30 years (
Univariable and multivariable logistic regression models for the association between SLT use and sociodemographic characteristics.
| Age | 15–30 years | Reference | |
| 31–45 years | 2.03 (1.71–2.40) | 1.66 (1.37–2.00) | |
| 46–60 years | 1.82 (1.49–2.24) | 1.41 (1.12–1.78) | |
| >60 years | 1.68 (1.32–2.15) | 1.45 (1.08–1.93) | |
| Gender | Male | 1.36 (1.26–1.46) | 2.37 (1.94–1.90) |
| Female | Reference | ||
| Residence | Urban | Reference | |
| Rural | 1.52 (1.20–1.92) | 0.94 (0.73–1.22) | |
| Region | North | 0.26 (0.12–0.58) | 0.46 (0.21–0.99) |
| Central | 3.03 (2.29–4.02) | 3.50 (2.61–4.70) | |
| East | 3.91 (2.94–5.20) | 4.71 (3.51–6.32) | |
| Northeast | 2.87 (2.20–3.74) | 4.88 (3.66–6.50) | |
| West | 1.85 (1.34–2.55) | 2.24 (1.61–3.13) | |
| South | Reference | ||
| Educational qualification | No formal education | 3.88 (2.62–5.74) | 3.25 (2.02–5.23) |
| Primary incomplete | 4.45 (2.94–6.76) | 2.82 (1.73–4.59) | |
| Primary but not secondary | 4.25 (2.85–6.35) | 3.35 (2.10–5.34) | |
| Secondary and higher secondary | 1.64 (1.06–2.54) | 1.61 (0.99–2.64) | |
| Graduation and above | Reference | ||
| Occupation | Govt. and non–govt. employee | 4.45 (2.71–7.31) | 4.14 (2.41–7.10) |
| Daily wage/casual laborer | 8.18 (5.48–12.21) | 5.32 (3.39–8.34) | |
| Self–employed | 7.68 (5.12–11.54) | 4.84 (3.09–7.59) | |
| Homemaker | 2.55 (1.69–3.85) | 2.44 (1.54–3.86) | |
| Unemployed | 5.53 (3.47–8.82) | 3.92 (2.36–6.52) | |
| Student | Reference | ||
| Wealth index | Poor class | 2.24 (1.70–2.96) | 1.48 (1.06–2.07) |
| Middle class | 1.96 (1.49–2.57) | 1.33 (0.97–1.84) | |
| Rich class | Reference | ||
| Smoking tobacco | Yes | 1.14 (0.95–1.38) | 0.59 (0.47–0.75) |
| No | Reference | ||
We found a high proportion of SLT users from central India (30.1%) and Eastern India (31.2%) were willing to quit tobacco use. In addition, a higher proportion of tribal people who attempted to quit SLT belonged to the central (33.6%) and eastern (31.6%) regions of India (
Regional differences between willingness to quit tobacco and attempted to quit tobacco.
| 7, 0.39% (0.15–0.77) | 5, 0.52%, (0.16–1.13) | |
| 563, 30.13%, (28.04–32.26) | 346, 33.57%, (30.68–36.53) | |
| 583, 31.19%, (29.10–33.35) | 326, 31.61%, (28.79–34.56) | |
| 277, 14.83%, (13.24–16.51) | 107, 10.42%, (8.58–12.40) | |
| 244, 13.05%, (11.56–14.67) | 101, 9.78%, (8.05–11.78) | |
| 195, 10.41%, (9.08–11.91) | 146, 14.12%, (12.00–16.34) |
We observed the overall prevalence of SLT to be high. Respondents of middle age, male, northeastern region, fewer years of education, daily wage/casual laborers, and poor wealth quintile were associated with smokeless tobacco consumption among tribes. In the eastern region, people were more willing to quit SLT, whereas a higher proportion of respondents from central India attempted to quit SLT.
In the current study, the mean age of initiation of SLT was 20.7 (±8.0) years. However, our findings are slightly higher than a study conducted among the tribal community of West Bengal, which found the mean age of initiation of SLT to be ~17.5 years (
This study highlighted the overall prevalence of SLT use among tribal to be approximately 32% which is in harmony with the results of a similar study conducted among urban tribes in Madhya Pradesh that found the prevalence of SLT to be approximately 37.2% (
The current study suggests that the prevalence of SLT was highest among participants aged 31–45 years, which adheres to the findings of a study conducted among the rural tribes of Nagaland where the use of SLT was highest among respondents aged 25–44 years (
We also observed an association between SLT consumption and lower educational attainment. Our result is in harmony with the observations of a study from Madhya Pradesh, which showed tribal individuals with primary education rampantly used SLT (
In the present study, the northeastern region was found to be the highest utilizer of smokeless tobacco, followed by the eastern region. This is similar to the findings of NFHS-5 (2019–2021), a nationally representative survey, which suggested that the prevalence of SLT consumption among the general population was higher in the northeastern states (
We observed a higher proportion of people from Eastern India and central India were willing to quit SLT and have attempted to do so, which indicates that these people can easily be persuaded to quit tobacco. Tailored anti-tobacco messages in the local language may prove to be beneficial. Personal support, if required, may be extended by program implementers, which will aid in quitting tobacco. Tobacco taxes are a proven strategy for reducing tobacco consumption and also restraining the availability of these products (
Findings from the current study reflect that the prevalence of SLT consumption is much higher among tribes than the general population, which calls for urgent action in the tribal-dominated regions. The existing program should be implemented in such a way that it should be culturally acceptable as well as linguistically understandable among these groups to create a positive effect. Though the prevalence of SLT use was high among men, SLT use is reasonably rising among women than smoking, which poses equivalent health hazards (
The consumption of SLT products was relatively greater than the general/non-tribal population. The use of SLT was more among tribal individuals with fewer years of schooling, who should be focused while planning for health awareness, tobacco cessation activities, or behavior change communication (BCC). Mass media advertisements or camps could be conducted, where visual or graphical presentations must be a part of awareness, which can be beneficial for all segments of society. The involvement of tribal leaders and celebrities in anti-tobacco campaigns in their local language may arouse interest in the subject. Folk dances, puppet shows, and other traditionally acceptable activities can be implemented. Special attention to tobacco cessation policies is essential for the seven sisters of northeast India, owing to the pervasiveness of the higher burden.
The Global Adult Tobacco Survey (GATS) provides an extensive and nationally representative dataset with better generalizability of the findings. We considered the self-reported cases of SLT use, which may lead to underestimation (misclassification bias and recall bias) of the actual burden of tobacco. The cross-sectional design hampered our abilities to draw causal relationships.
This study highlights the high burden of tobacco use along with its social determinants, which can help in tailoring the tobacco control program among tribes in India. Tobacco control programs should target men, rural residents, and individuals with fewer years of schooling. Future studies should explore the behavioral and social linkages to tobacco use among tribal communities.
The original contributions presented in the study are included in the article/
SG, AS, SK, and SP: conceptualization and methodology. AS and SP: data curation. RA, JM, and SG: formal analysis. SK and SP: software and supervision. RA, JM, SG, and AS: writing the original draft. SP, HK, and SK: writing, reviewing, and editing. All authors contributed to the article and approved the submitted version.
The authors are grateful to the Global Adult Tobacco Survey (GATS) for assembling and publishing accurate, nationally representative data on a range of utilization of various forms of tobacco, and their indicators for the population in the age range of 15 years and older.
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.
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