Trends in bidi and cigarette smoking in India from 1998 to 2015, by

Research
Trends in bidi and cigarette smoking
in India from 1998 to 2015, by age,
gender and education
Sujata Mishra,1 Renu Ann Joseph,1 Prakash C Gupta,2 Brendon Pezzack,1
Faujdar Ram,3 Dhirendra N Sinha,4 Rajesh Dikshit,5 Jayadeep Patra,1 Prabhat Jha1
To cite: Mishra S,
Joseph RA, Gupta PC, et al.
Trends in bidi and cigarette
smoking in India from 1998
to 2015, by age, gender and
education. BMJ Global Health
2016;1:e000005.
doi:10.1136/bmjgh-2015000005
▸ Additional material is
published online only. To
view please visit the journal
online (http://dx.doi.org/10.
1136/bmjgh-2015-000005).
Received 30 October 2015
Revised 13 January 2016
Accepted 19 January 2016
1
Centre for Global Health
Research, St. Michael’s
Hospital and Dalla Lana
School of Public Health,
University of Toronto,
Toronto, Ontario, Canada
2
Healis-Sekhsaria Institute of
Public Health, Mumbai,
Maharashtra, India
3
International Institute of
Population Studies, Mumbai,
Maharashtra
4
World Health Organization
Regional Office of South East
Asia, New Delhi, India
5
Tata Memorial Hospital,
Mumbai, Maharashtra, India
Correspondence to
Professor Prabhat Jha;
[email protected]
ABSTRACT
Objectives: Smoking of cigarettes or bidis (small,
locally manufactured smoked tobacco) in India has
likely changed over the last decade. We sought to
document trends in smoking prevalence among
Indians aged 15–69 years between 1998 and 2015.
Design: Comparison of 3 nationally representative
surveys representing 99% of India’s population; the
Special Fertility and Mortality Survey (1998), the
Sample Registration System Baseline Survey (2004)
and the Global Adult Tobacco Survey (2010).
Setting: India.
Participants: About 14 million residents from 2.5
million homes, representative of India.
Main outcome measures: Age-standardised
smoking prevalence and projected absolute numbers of
smokers in 2015. Trends were stratified by type of
tobacco smoked, age, gender and education level.
Findings: The age-standardised prevalence of any
smoking in men at ages 15–69 years fell from about 27%
in 1998 to 24% in 2010, but rose at ages 15–29 years.
During this period, cigarette smoking in men became
about twofold more prevalent at ages 15–69 years and
fourfold more prevalent at ages 15–29 years. By contrast,
bidi smoking among men at ages 15–69 years fell
modestly. The age-standardised prevalence of any
smoking in women at these ages was 2.7% in 2010. The
smoking prevalence in women born after 1960 was about
half of the prevalence in women born before 1950. By
contrast, the intergenerational changes in smoking
prevalence in men were much smaller. The absolute
numbers of men smoking any type of tobacco at ages
15–69 years rose by about 29 million or 36% in relative
terms from 79 million in 1998 to 108 million in 2015.
This represents an average increase of about 1.7 million
male smokers every year. By 2015, there were roughly
equal numbers of men smoking cigarettes or bidis. About
11 million women aged 15–69 smoked in 2015. Among
illiterate men, the prevalence of smoking rose (most
sharply for cigarettes) but fell modestly among men with
grade 10 or more education. The ex-smoking prevalence
in men at ages 45–59 years rose modestly but was low:
only 5% nationally with about 4 current smokers for
every former smoker.
Conclusions: Despite modest decreases in smoking
prevalence, the absolute numbers of male smokers aged
15–69 years has increased substantially over the last
Key questions
What is already known about this topic?
▸ India has over 100 million adult smokers, the
second highest number of smokers in the world
after China.
▸ There are already about 1 million adult deaths
per year from smoking.
What are the new findings?
▸ The age-standardised prevalence of smoking
declined modestly among men aged 15–69 years,
but the absolute number of male smokers at these
ages grew from 79 million in 1998 to 108 million
in 2015. This is due to population growth offsetting modest declines in prevalence.
▸ Cigarettes are displacing bidis, especially among
younger men and among illiterate men. This
change might further increase the smoker: non
smoker relative risks of disease.
▸ Smoking cessation remains uncommon—only
about 5% of men aged 45–59 years are
ex-smokers. India has about 4 current male
smokers for every quitter at these ages.
▸ Female smoking at ages 15–69 years has not
likely risen.
Recommendations for policy
▸ More effective tobacco control policy including
higher tobacco taxation for cigarettes needs to be
implemented as a short-term priority. India’s complicated tax structure has kept overall taxes on
cigarettes low relative to other countries, with particularly low taxes on the less-expensive, short
cigarettes that compete with the bidi market.
Longer term policies need to raise taxes on bidis.
▸ Intervention programmes to raise the currently
low levels of tobacco cessation are needed.
▸ Use of reliable, representative, large scale population surveys can help monitor the evolution of
smoking and its consequences.
15 years. Cigarettes are displacing bidi smoking, most
notably among young adult men and illiterate men.
Tobacco control policies need to adapt to these
changes, most notably with higher taxation on tobacco
products, so as to raise the currently low levels of adult
smoking cessation.
Mishra S, et al. BMJ Glob Health 2016;1:e000005. doi:10.1136/bmjgh-2015-000005
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INTRODUCTION
Tobacco smoking is among the largest preventable
causes of premature deaths globally.1 In 2010, an estimated 120 million Indian adults smoked, making India
second only to China in number of smokers.2 3
Historically, most of the smoked tobacco in India has
been in the form of bidis, small locally made cigarettes
with tobacco wrapped inside a Tendu leaf. In 2010,
smoking caused about 1 million deaths, or 10% of all
deaths in India, with about 70% of these deaths occurring at the ages of 30–69 years.4 5 The patterns of use of
bidis or manufactured cigarettes vary across different
regions and socioeconomic levels.6 7 Smoking cessation
is far less common than in high-income countries.3 4 8 9
The consumption pattern of tobacco has likely
changed over the last decade in response to substantially
higher income in India paired with population growth
and perhaps in response to modest tobacco control
efforts.10 We examine three nationally representative
surveys covering over 2.5 million homes and 14 million
people to provide estimates of the changing trends from
1998 to 2015 in any tobacco smoking, in bidi and cigarette smoking, and in smoking cessation. We examine
these trends by gender, age and generation, education
level, and urban and rural residence.
METHODS
Survey populations
We estimated smoking prevalence using three large,
nationally representative surveys in India: the Special
Fertility and Mortality Survey (SFMS) (1998), Sample
Registration System Baseline Survey (SRSBS) (2004) and
the Global Adult Tobacco Survey (GATS) (2010).
The Registrar General of India (RGI) divides India
into small geographic areas called Sample Registration
System (SRS) units, based on the preceding census, to
estimate vital rates nationally and for each state. In 1993,
the RGI randomly selected 6671 of these small areas
(4436 rural and 2235 urban) from the 1991 census to
form the 1993–2003 SRS frame. The SFMS was undertaken in these SRS units starting in February 1998, covering approximately 6 million people living in
approximately 1.1 million households across India.
Jammu and Kashmir and the rural units of Nagaland
(<1% of India’s population) were excluded due to operational problems.11 In 2004, the RGI randomly selected
7597 areas (4433 rural and 3164 urban) from the 2001
census, to form the 2004–2013 SRS frame. The SRSBS
was conducted over several months in 2004, covering 1.3
million households in all Indian states and union territories.12 In 2010, the GATS surveyed over 79 690 nationally representative households selected from the 2001
census enumeration blocks and villages for urban and
rural areas, respectively. The GATS covered all noninstitutionalised adults within 29 states and two union
territories (Chandigarh and Puducherry). A total of
69 296 adults completed the interview and provided self2
reported information on their smoking habits.3 The
survey design and sample framework details, field
methods and quality control steps for each survey have
been published.3 11–13 We applied Indian census definitions for education (illiterate or with no formal education, less than grade 10 education and grade 10 or more
education), and for rural and urban residency status.
Definitions of smoking
Most of the respondents in the 1998 SFMS and the 2004
SRSBS were male heads of the household and provided
personal information as well as proxy information on
other household members, including their wives. The
SFMS asked respondents if household members aged
10 years or older were current smokers (combining occasional and daily smokers); and if yes, whether they smoked
cigarette or bidis. The SRSBS asked respondents if
persons aged 15 years or older were usual smokers, occasional smokers, ex-smokers or never-smokers; we defined
current smokers as usual or occasional smokers. The 2010
GATS randomly selected one individual respondent from
each household and asked them to categorise themselves
into daily smokers, less than daily smokers, ex-smokers or
never-smokers; we defined current smokers as daily or as
less than daily smokers. The SRSBS did not publish information on type of tobacco smoked, and reported statistics
only for age groups 15–29, 30–44, 45–59 and 60 years or
older. Ex-smoking was reported only in the 2010 GATS
and in the 2004 SRSBS, the latter only for any smoking.
Respondents who smoked cigarettes or bidis exclusively
were classified as ‘exclusive’ while respondents who
smoked both cigarettes and bidis were classified as ‘both’.
We also included ‘any smokers’ as a separate category for
those who were either exclusive or both or smoked any
other type of tobacco including hookah, cheroot, etc.14
Analysis
We analysed all states and union territories but retained
three states formed after the 1991 census within their
original states (thus, Madhya Pradesh and Chhattisgarh,
Bihar and Jharkhand, and Uttar Pradesh and
Uttarakhand, are listed as pairs). We combined the
smaller states of the Northeast (except Assam) to
include Arunachal Pradesh, Manipur, Meghalaya,
Mizoram, Nagaland, Sikkim and Tripura. Sample framework and weights were used to derive prevalence estimates. Analyses were conducted in STATA V14.0.
We standardised smoking prevalence to the age distribution of the 2011 Indian Census.15 We tested statistical significance of the differences between the surveys by
age-standardised rate ratios (ASRRs) with 99% CIs.
Estimates of the absolute number of smokers for both
genders in 1998 applied the survey age-specific prevalence
to the interpolated population totals from the 1991 to
2001 censuses. Estimates of the absolute number of
smokers in 2015 applied annual rates of change in
smoking prevalence between 1998 and 2010, for each age
and state strata for men and 15–69 years for women, to the
Mishra S, et al. BMJ Glob Health 2016;1:e000005. doi:10.1136/bmjgh-2015-000005
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2015 United Nations population totals.16 Throughout, we
focus on smoking at ages 15–69 years for three reasons.
First, smoking trends among ages 70 years or older are less
reliably ascertained (due in part to higher absolute mortality rates from smoking at older ages).17 Second, India’s
age structure is still quite young, with 80% of India’s population being below 45 years of age.16 Third, about 70% of
tobacco deaths in India are reported at ages 30–69 years.4
Hence, the more important public health goal is avoidance of death in middle versus older age.18
RESULTS
We were able to report on men and women in 29 Indian
states representing 99% of India’s population ( Jammu
and Kashmir, and 7 of the 8 union territories were
excluded from 1 or 2 of the surveys). Individual level
data on smokers analysed about 530 000 men and
32 000 women above age 15 years in 1998, and 10 000
men and 1200 women in 2010 (see web table 1).
The age-specific prevalence of any smoking in men
followed a similar pattern in 1998 and 2010, peaking at
about 50 years of age and declining at older ages. At
most ages, the age-specific prevalence was significantly
lower in 2010 than in 1998 (figure 1). The notable
exception was in men aged 15–29 years, among whom
the age-specific prevalence was higher in 2010 than in
1998. The age-specific prevalence of any smoking in
women showed a very different pattern than that for
men, with prevalence peaking above 60 years of age.
The observed increases in the age-specific prevalence in
women between the 1998 and 2010 surveys were concentrated mostly at these older ages. Age-specific prevalence
rates in men in 2004 for any smoking at ages 15–29, 30–
44 and 45–59 years, were in between the 1998 and 2010
results (see web table 2A–C), consistent with modest
increases at ages 15–29 years and modest declines in the
latter two age groups.
The age-standardised prevalence of any smoking in men
aged 15–69 years fell from about 27% in 1998 to 24% in
2010 (change per decade −2.0%, ASRR=0.9, 99% CI 0.9
to 0.9; figure 2). The age-standardised prevalence of any
smoking in women aged 15–69 years rose from 1.4% in
1998 to 2.7% in 2010, but this might well be an artefact of
the survey methodology as most of the reported increase
occurred at older ages. The SFMS of 199812 13 19 relied on
proxy reporting by male heads of household and they
likely under-reported female smoking,20–22 whereas the
smoking prevalence was more accurately captured from
self-reports in the GATS of 2010.3 The changes between
1998, 2004 and 2010 did not show consistent increases in
smoking in young adult women, as would be expected if
there were an increase in female smoking. In each time
period, smoking prevalence at ages 30–69 years in women
born after 1960 was about half of the prevalence in
women born before 1950. By contrast, the intergenerational changes in smoking prevalence in men at these ages
were much smaller (figure 3). As few women smoked,
most of the following results focus on men.
The age-standardised prevalence of any smoking
among men aged 15–69 years rose significantly in Delhi,
Kerala, Odisha, Punjab and the Northeast States but fell
modestly in other states (figure 2). The age-standardised
prevalence of any smoking in men aged 15–29 years rose
(9–12%; change per decade +2.4%, ASRR=1.3, 1.2 to
1.4), but fell at older ages. These trends markedly
diverged between cigarettes and bidis (figure 4).
Cigarette smoking became more prevalent at ages 15–
69 years (change per decade +4.8%, ASRR 2.2, 2.1 to
2.2) with large increases at ages 15–29 years (change per
decade +4.5%, ASRR 3.9, 3.6 to 4.2) and smaller, but
still significant, increases at older ages. By contrast, the
age-standardised prevalence of bidi smoking among
men fell at ages 15–69 years (change per decade −2.3%,
ASRR 0.9, 0.8 to 0.9), and within each age group.
Figure 1 Smoking prevalence
by age and gender (with 99% CI):
1998–2010. GATS, Global Adult
Tobacco Survey; SFMS, Special
Fertility and Mortality Survey.
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Figure 2 Age-standardised smoking prevalence among adults aged 15-69 years, by state: 1998–2010, absolute change (%)
per decade and number of smokers in 2015 (in millions). GATS, Global Adult Tobacco Survey; SFMS, Special Fertility and
Mortality Survey. Note that reliable estimates for absolute changes per decade could not be estimated for women. We applied
GATS 2010 smoking prevalence for women ages 15-69 years to the 2015 population.
Even using the GATS definition of exclusive smoking, cigarette smoking rose substantially and bidi smoking fell
modestly (data not shown). Cigarette smoking rose more
in rural men than in urban men while bidi smoking fell
modestly in both areas for nearly all age groups except at
ages 15–29 years (see web figures 1A,B).
The highest age-standardised prevalence of any smoking
in men aged 15–69 years was in illiterate men in both 1998
and 2010 (see web table 3). Among illiterate men at these
ages, the prevalence of cigarette, bidi or any smoking rose
(figure 5), most sharply for cigarettes. By contrast, among
men with grade 10 or more education, the prevalence of
Figure 3 Smoking prevalence
by decade of birth cohort and
gender: 1998–2010. Note:
Numbers near each point
represent the sample size. GATS,
Global Adult Tobacco Survey;
SFMS, Special Fertility and
Mortality Survey.
4
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bidi or any smoking fell. Even among these more educated
men, cigarette smoking rose modestly.
As the age-specific rates in 1998, 2004 and 2010
showed consistent increases at ages 15–29 years and
modest declines at older ages, we were able to make
reasonably sensible forward projections to 2015. The
absolute numbers of men smoking any type of tobacco
at ages 15–69 years rose by about 29 million or 36% in
relative terms from 79 million in 1998 to 108 million in
2015 (figure 4, bottom panel), representing an average
annual increase of about 1.7 million male smokers. The
number of any smokers at these ages rose in urban
India by about 68% from 19 to 31 million and the
number in rural India increased about 26% from 61 to
77 million. The five largest relative increases over one
decade in the absolute number of male smokers aged
15–69 years were in Delhi (220%), Punjab (120%), the
North East states excluding Assam (60%), Odisha
(50%) and Maharashtra (40%). Decreases in the absolute number of male smokers were observed in only
two states—Goa and Assam (see web table 1). In 2015,
we estimate that approximately 61 million Indian adult
men aged 15–69 years smoked cigarettes (40 million
exclusively) and 69 million smoked bidis (48 million
exclusively). At ages 15–69 years, and assuming that the
prevalence in GATS in 2010 was unchanged by 2015,
there were about 11 million women who smoked, about
one-tenth the total of men who smoked. Given higher
mortality and greater reporting problems at older ages,
there were, less reliably, an estimated 6 million men and
2.5 million women smokers at ages 70 years and above.
Smoking cessation among men is best measured at
ages 45–59 years, well after the peak of smoking initiation and when smokers are more likely to be aware of
health hazards that could prompt cessation.17 The agespecific ex-smoking prevalence in men at these ages rose
modestly from 2004 to 2010, from about 2% to 5%
nationally (figure 6), with variation in the ex-smoking
prevalence across states in 2010 ranging from 19% in
Kerala to <1% in Punjab. The ratio of current to former
smokers in men at these ages was 4 in 2015 for India,
ranging from 1 in Kerala and Bihar/Jharkhand to 60 in
West Bengal. Very few women were ex-smokers.
DISCUSSION
The Indian government implemented the Cigarettes and
Other Tobacco Products Act (COTPA)23 in 2003 and ratified the WHO’s Framework Convention on Tobacco
Control in 2004, as well as the Cable Television Networks
(Amendment) Act 2000 prohibiting tobacco advertising
in all state-controlled electronic media and publications,
including cable television.24 25 Further, the Government
has also included tobacco control in the priorities of the
ongoing National Rural Health Mission.26 Despite these
programmes, the major challenge to success is effective
implementation of the provisions of COTPA, especially in
enforcement of bans on smoking in public places (which
are known to raise cessation rates).1 24 Most importantly,
these trends in smoking reflect the lack of substantial
increases in tobacco excise taxes, which have not kept up
with the increased affordability of cigarettes and bidis.10
Figure 4 Age-standardised rate (ASR) of smoking among men by age group, product between 1998 to 2010 and number of
smokers in 2015 (in millions). ASRR, age-standardised rate ratios between the Global Adult Tobacco Survey and the Special
Fertility and Mortality Survey.
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Figure 5 Age-standardised rate (ASR) of smoking among
men aged 15 to 69 years by product, and by two levels of
education: 1998–2010. ASRR, age-standardised rate ratios
between the Global Adult Tobacco Survey and the Special
Fertility and Mortality Survey.
Hence, tobacco control in India urgently requires effective implementation of national policies.
Our study of nationally representative Indian surveys
over more than a decade finds substantial increases in the
number of male smokers aged 15–69 years, rising over
one-third since 1998 to nearly 108 million in 2015. The
increase is mostly due to population growth offsetting the
modest declines in prevalence over this time period,
similar to the pattern observed in other countries.27 There
is a clear shift in consumption away from bidis towards
manufactured cigarettes. The sharpest relative and absolute increase was for cigarette smoking, particularly in
young adult men aged 15–29 years. The increases in cigarette use among younger adult men were seen in rural
areas and were greatest among illiterate men.
Rapid income growth over the last decade has most
likely contributed to the shift in smoking—from the
less-expensive bidis to cigarettes. Price is the most
important determinant of consumption. Relative to
income, cigarettes and bidis have become less costly in
the last decade.10 Moreover, and most relevant for
policy, India’s complicated tax structure has kept overall
taxes on cigarettes low relative to other countries, with
particularly low taxes on the inexpensive, short cigarettes that compete with the bidi market.28–30 The
increase in cigarette smoking is consistent also with
market reports showing that the absolute volume of
cigarettes sold in India has risen from about 98 billion
sticks in 2000 to 114 billion in 2012.31 Unfortunately,
bidi sales data are unavailable, as most bidis are sold by
small cottage industries with little monitoring or regulation and attract low or no taxes.32
Figure 6 Ex-smoker rates in India among men (45–59 years) from 2004 to 2010; absolute number (in million) of smokers and
ex-smokers in 2015. GATS, Global Adult Tobacco Survey; UN, United Nations. Note that, * it is unlikely that smoking cessation
has decreased from 2010-2015. Therefore we assigned GATS 2010 ex-smoking prevalence to Assam, West Bengal and Punjab
which reported a decline. Odisha was excluded from the analyses due to few numbers of smokes in the GATS. †We applied
GATS 2010 smoking and ex-smoking prevalence for women to estimate 2015 absolute totals. ‡The number of smokers and exsmokers are based on 2015 UN Population totals for India.
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The observed increase in female smoking is likely to
be an artefact of reporting. A true increase in smoking
would be expected among younger women, who have
seen more rapid income growth, and are the subject of
tobacco industry promotion. However, among younger
adult women, there was little increase in smoking
(figure 1, see web table 1), and indeed smoking prevalence was less than half of that seen in older generations. Among female respondents in the ongoing
Million Death Study (conducted in the same areas as
the SRSBS), there has been no major shift in smoking
patterns among younger women from 2004 to 2013
(data not shown). Among selected high schools in particular regions of India, there are reports that female
and male smoking at very young ages (13–15 years) are
more equal,33 and, in the future, young women, particularly in urban areas, could take up cigarette smoking.
A robust measure of successful tobacco control policies is rapid increases in ex-smoking prevalence among
later age adults.17 34 We find that smoking cessation
remains uncommon in India: only about 5% of the men
aged 45–59 years were ex-smokers in 2010, a modest
increase from 2004. A similarly helpful statistic is the
ratio of current to former smokers. India has about four
current male smokers for every quitter at these ages. By
contrast, in the USA and other high-income countries,
there are now as many ex-smokers as current smokers at
these ages.35 36 Countries that are more comparable to
India in income but adopted tobacco control earlier
(including through tax increases) now have a substantially higher prevalence of quitting.37
The absolute number of tobacco-attributable deaths
among India’s 120 or so million smokers will continue to
rise. The exact totals depend on the risks of smoking cigarettes or bidis, the age of initiation and background mortality rates from causes other than smoking. Indian male
smokers traditionally start smoking later in life4 and smoke
fewer sticks per day when compared with male smokers in
high-income countries.9 Nonetheless, the smoker versus
non-smoker risk ratios for dying from smoking attributable
causes remain high in India.4 Unlike in China,38 we did
not see a dramatic shift to smoking at younger ages (data
not shown) among men. Some, but not all, studies have
shown that the relative risk of tobacco attributable causes
of death is greater for cigarette than for bidi smoking.4 14
The risks of death among cigarette smokers who smoke
more than eight cigarettes per day, closer to smoking
patterns in the USA or Canada, are particularly pronounced.1 39 Future risks will also depend on whether the
currently low quit rates rise substantially.
Our analyses need to consider a few limitations. First,
the SFMS and the SRSBS relied on proxy reporting by
the head of the household, which has shown in some
direct comparisons to be valid20–22 and tightly correlated
with self-reports. However, other studies find that the
correlation between proxy and self-responses varies,40
including by gender or relationship status of the
respondent and subject.41 The reported increase in
female smoking prevalence at older ages between the
1998 SFMS or 2004 SRSBS and the 2010 GATS suggests
a reporting bias from husbands unaware of or unwilling
to disclose their wife’s smoking. Proxy reporting might
also result in under-reporting of smoking at younger
ages. However, other surveys42 43 find prevalence fits
with increased consumption among younger adult men.
Second, whereas the GATS allowed smokers to selfidentify smoking multiple products, the SFMS required
classifying smokers as either cigarette smokers or bidi
smokers. Thus, we might have underestimated cigarette
and bidi smoking prevalence rates in the 1998 baseline,
and exaggerated the actual increase by 2010. Such misclassification of cigarette or bidi smoking would not affect
the findings for any smoking prevalence. Moreover,
smoking prevalence among living respondents in the
ongoing Million Death Study finds also an increased use
of cigarettes relative to bidis. Lastly, the sampling frame
for the surveys differed, being much larger for SFMS and
SRSBS than GATS, and the GATS method of selecting
households may have missed (the few) adults living
alone.3 All three sampling frames were nationally representative, with large sizes, and likely accurately captured
the true underlying trends in male smoking.
A substantial reduction in smoking is central to achieving the United Nations’ 2030 goals to decrease premature death from non-communicable disease.18 Apart
from effective implementation of the WHO’s recommended measures, including increasing tobacco taxation,1 the use of reliable, representative, large scale
population surveys is helpful in accelerating tobacco
control policies and in monitoring their impact, particularly in raising the low rates of smoking cessation in
India.
Acknowledgements The authors thank Krishna Palipudi for his valuable
inputs while drafting and revising the manuscript, and Mehak Bhatia for
graphics.
Contributors PJ, SM and RAJ contributed to the conception and design of
the study. PJ, SM, RAJ and BP contributed to the analysis and interpretation
of the data. All the authors performed the drafting of the manuscript for
important intellectual content.
Funding This work was supported by the University of Toronto and the Bill
and Melinda Gates Foundation (51447).
Disclaimer The funders had no role in study design, analysis, interpretation of
results, writing of the report, nor in the decision to submit this article for
publication.
Competing interests None declared.
Ethics approval International Institute of Population Sciences, Mumbai and
Ministry of Health, New Delhi, India.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The GATS data are publicly available (Link: http://
www.who.int/tobacco/surveillance/gats/en/; India Report: Global Adult
Tobacco Survey: India Report. Mumbai, India: International Institute for
Population Sciences (IIPS), Ministry of Health and Family Welfare GoI, 2010).
The SFMS and SRS baseline key results have been published, but the data are
provided under special agreement with the Registrar General of India and are
not yet in the public domain. Basic data tables from SFMS, SRS baseline and
GATs are provided as web-tables for reference. (Reference 1: Special Fertility
Mishra S, et al. BMJ Glob Health 2016;1:e000005. doi:10.1136/bmjgh-2015-000005
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and Mortality Survey 1998: a report on 1 million homes. New Delhi, India:
Registrar General of India, 2005; 2: Sample Registration System: Statistical
Report 2004. New Delhi, India: Registrar General of India, 2005).
21.
22.
Open Access This is an Open Access article distributed in accordance with
the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,
which permits others to distribute, remix, adapt, build upon this work noncommercially, and license their derivative works on different terms, provided
the original work is properly cited and the use is non-commercial. See: http://
creativecommons.org/licenses/by-nc/4.0/
23.
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Supplementary Appendix
Web Table 1: Number of smokers in India (sample and population): 1998 and 2010.
Number of smokers studied Number of smokers (000)
State and Region
1998/2010
1998
2015
Annual absolute
change (%)
10,998/360
674
839
1.4
Punjab
4095/160
560
1700
12.0
Chandigarh
2175/204
64
84
1.9
24,254/364
2291
3231
2.4
4815/328
612
2851
21.5
Men 15-69 Years
Himachal Pradesh
Haryana
Delhi
Rajasthan
34,952/370
5286
8035
3.1
Uttar Pradesh & Uttaranchal
54,445/821
14,523
18,014
1.4
Bihar & Jharkhand
38,646/381
7413
7855
0.4
Assam
28,840/713
3044
2340
-1.4
West Bengal
67,614/652
11,058
13,582
1.3
Odisha
15,667/230
1878
3488
5.0
Madhya Pradesh & Chhattisgarh
31,865/479
6168
9165
2.9
Gujarat
20,659/258
3443
4242
1.4
Maharashtra
12,906/326
3441
5707
3.9
Andhra Pradesh
30,599/416
7323
9605
1.8
Karnataka
27,452/217
3863
5333
2.2
3924/84
76
33
-3.3
Kerala
21,462/230
2270
3534
3.3
Tamil Nadu
20,636/268
3575
5315
2.9
Northeast
44,693/2379
1386
2796
6.0
Rural Men
41,2042/6449
60,957
76,718
1.5
Urban Men
96,965/3321
18,746
31407
4.0
INDIA TOTAL
509,007/9770
79,428
108,125
2.1
Total 70+
21,864/478
4128
5896
2.5
Total 15+
530,871/10248
83,437
114,021
2.2
11,183
-*
Goa
Women 15-69 Years
INDIA TOTAL
31,949/1214
Note: * Reliable estimates for annual absolute change (%) for women could not be estimated since we believe that smoking among women has been declining based on
our estimation by birth cohorts.
Web Table 2a: The 1998 and 2010 age standardized smoking prevalence for ages 15-69 years and 15-29 years, by state and
location of residence and the 2004 non-standardized rates of smoking for 15-29 years *.
States/ Regions
15-69 years
Total
Rural
1998 2010 1998 2010
Urban
1998 2010
Total
1998 2004
2010
15-29 years
Rural
1998 2004 2010
Urban
1998 2004 2010
Men
Himachal Pradesh
38.2
33.1
38.2
33.1
38
33.1
12.1
8.0
13.7
12.2
7.8
12.7
11.0
8.6
19.6
7.5
12.7
7.5
12.8
7.5
12.7
3.0
5.4
8.3
2.6
4.8
5.4
3.7
7.0
12.6
Chandigarh
19.4
18.0
18.9
16.5
19.4
18.1
11.4
11.2
9.6
21.9
17.8
19.3
9.9
7.5
8.3
Haryana
38.2
32.3
37.9
32.0
38.8
32.9
16.0
17.2
12.7
19.2
20.6
14.3
7.4
10.8
9.3
Delhi
13.9
31.4
13.5
31.0
13.9
31.4
4.8
10.3
20.8
6.5
10.5
9.8
4.7
10.3
21.1
Rajasthan
34.7
31.9
34.6
31.7
35.1
32.4
14.3
21.4
12.8
16.0
24.7
13.2
9.0
5.8
11.5
Uttar Pradesh/ Uttaranchal
30.8
25.1
30.8
25.1
30.6
24.9
10.0
13.8
9.9
10.6
15.2
11.0
7.9
8.3
6.0
Bihar/ Jharkhand
25.8
19.6
25.8
19.6
25.6
19.5
7.9
12.0
16.0
8.3
14.1
16.8
5.7
6.8
11.2
Assam
39.8
25.7
39.4
25.5
42.0
26.6
15.0
18.9
15.4
15.7
23.0
14.2
10.7
16.0
21.1
West Bengal
44.7
39.2
44.0
38.8
46.2
40.1
20.7
19.8
23.9
21.7
21.5
23.8
18.0
15.3
24.1
Odisha
17.5
20.4
17.5
20.3
17.4
20.6
6.0
11.7
10.1
6.5
12.7
10.1
3.8
8.2
11.0
Madhya Pradesh/ Chhattisgarh
27.4
25.7
27.3
25.7
27.5
25.8
8.8
12.8
16.2
10.2
16.7
15.4
5.1
5.3
19.6
Gujarat
22.8
18.8
22.9
19.0
22.6
18.7
7.5
9.5
3.7
6.9
10.9
3.5
8.3
5.4
4.0
Maharashtra
11.6
12.2
11.6
12.2
11.6
12.1
2.6
2.8
4.8
2.7
2.0
3.5
2.5
4.2
6.1
Andhra Pradesh
31.8
29.7
31.8
29.8
31.7
29.3
11.0
8.4
12.0
12.3
8.8
11.6
7.7
7.0
12.9
Karnataka
24.4
22.3
24.4
22.3
24.3
22.3
6.8
7.1
9.6
6.7
6.9
8.7
6.8
7.9
10.8
Goa
17.8
9.0
18.1
9.0
17.7
8.9
2.3
2.3
4.0
2.3
2.4
4.4
2.2
2.2
3.7
Kerala
24.6
27.8
24.5
27.8
24.7
27.9
6.9
9.0
16.6
7.7
9.7
14.6
4.7
5.8
22.6
Tamil Nadu
18.0
18.6
17.7
18.3
18.4
18.8
5.2
5.3
7.2
4.7
5.2
6.0
5.9
5.5
8.4
North East
39.4
48.6
39.0
48.4
40.2
49.1
17.6
21.7
34.9
18.2
22.0
34.5
16.0
20.3
35.9
INDIA TOTAL
26.7
24.3
29.3
26.0
21.0
20.4
9.4
11.8
12.3
10.4
13.0
12.8
7.0
8.8
11.1
1.4
2.7
1.6
3.3
0.9
0.4
0.6
1.3
0.5
0.7
1.5
0.7
0.5
0.8
0.2
Punjab
Women
INDIA TOTAL
*
Note: The 2004 estimates are age-specific prevalence estimates from SRSBL. SRSBL provided appropriate age specific patterns that are close to 2011 census population which is used as the standard
population for age standardized rates using SFMS and GATS.
2
Web Table 2b: The 1998 and 2010 age standardized smoking prevalence for ages 30-44 years and 45-59 years, by state and
location of residence and the 2004 non-standardized rates of smoking at these ages*.
States/ Regions
30-44 years
45-59 years
Total
Rural
Urban
Total
Rural
Urban
1998 2004 2010 1998 2004 2010 1998 2004 2010 1998 2004 2010 1998 2004 2010 1998 2004 2010
Men
Himachal Pradesh
51.1
38.1
40.2
52.0
41.9
40.9
45.5
30.9
34.6
62.6
47.7
57.3
64.6
54.9
60.2
49.4
34.3
37.5
Punjab
10.5
15.1
17.0
9.7
13.3
16.9
11.7
19.0
17.3
11.6
15.7
12.3
11.3
13.7
11.6
12.1
20.5
12.7
Chandigarh
28.6
28.0
20.5
45.6
31.0
27.1
26.5
26.8
19.6
23.5
26.0
28.2
35.0
28.0
47.2
22.7
25.5
26.4
Haryana
53.7
47.5
42.2
62.9
56.9
44.2
35.1
32.3
38.7
60.0
51.4
55.5
70.7
63.0
58.3
40.6
34.1
49.4
Delhi
20.3
29.6
35.4
26.6
33.6
63.1
20.0
29.1
34.7
23.0
34.5
37.9
31.4
46.4
71.6
22.6
33.0
36.8
Rajasthan
48.6
47.7
46.1
54.5
53.2
51.7
31.9
23.0
30.5
56.3
53.6
54.3
62.1
59.0
61.5
40.7
29.2
35.7
Uttar Pradesh/ Uttaranchal
44.2
40.2
33.7
46.7
43.5
36.8
36.5
27.4
24.1
54.3
45.1
42.9
57.4
48.6
45.3
44.8
32.2
36.6
Bihar/ Jharkhand
36.0
29.9
21.5
36.3
32.4
21.8
34.0
23.6
20.1
44.2
33.1
23.8
44.7
35.6
25.5
42.4
27.2
14.8
Assam
53.9
44.5
29.7
55.4
48.7
28.3
46.3
42.0
36.5
66.1
48.9
38.2
67.7
54.3
40.6
58.0
45.8
28.8
West Bengal
61.3
52.1
48.8
64.7
54.7
49.1
53.8
46.3
47.1
63.8
57.1
52.6
68.3
61.3
54.6
56.5
49.6
48.3
Odisha
24.3
31.3
29.5
25.2
32.5
31.8
19.9
26.9
22.3
27.5
57.5
26.5
27.6
38.3
27.5
26.9
32.2
24.3
Madhya Pradesh/ Chhattisgarh
38.7
33.4
28.5
42.7
39.3
29.7
28.3
22.4
23.4
46.6
39.2
39.1
50.3
44.6
43.4
37.7
29.4
21.4
Gujarat
29.1
31.2
23.0
32.0
35.5
27.9
24.8
18.3
16.6
40.0
42.0
40.5
44.7
47.4
47.5
32.5
23.3
29.2
Maharashtra
16.2
12.4
13.8
19.2
11.7
11.1
13.0
13.6
16.6
21.1
45.1
22.3
24.9
18.7
21.5
16.6
16.7
23.1
Andhra Pradesh
43.5
33.4
34.3
47.0
35.1
35.0
35.0
27.1
32.3
51.6
41.8
48.5
55.0
44.3
51.0
41.9
32.0
41.3
Karnataka
34.0
28.8
28.6
35.8
29.7
32.6
30.9
25.1
22.4
42.7
37.7
39.0
45.3
39.7
46.2
38.3
27.9
26.4
Goa
20.3
12.0
9.2
23.7
11.4
9.0
17.5
13.4
9.2
34.3
21.1
15.8
43.4
21.8
17.9
27.0
19.6
15.5
Kerala
32.0
39.5
32.4
33.8
42.4
35.0
27.2
27.3
25.4
38.2
47.9
37.1
41.0
51.1
38.9
31.0
34.6
34.2
Tamil Nadu
25.8
21.9
22.1
25.2
22.5
22.3
26.4
20.9
22.0
28.3
26.4
30.0
28.6
27.7
29.3
28.0
23.4
29.1
North East
54.1
52.7
57.2
55.7
53.3
60.7
49.2
50.3
47.2
63.6
57.5
62.2
65.8
58.1
67.0
57.6
55.3
48.6
INDIA TOTAL
37.3
34.6
29.8
41.1
37.2
32.1
29.2
28.3
24.9
43.7
40.5
38.2
47.9
43.8
41.6
35.1
32.5
30.8
1.4
2.2
2.7
1.7
1.6
3.4
0.9
0.9
0.3
2.4
3.7
5.0
2.8
2.8
6.2
1.4
1.4
0.8
Women
INDIA TOTAL
*
Note: The 2004 estimates are age-specific prevalence estimates from SRSBL. SRSBL provided appropriate age specific patterns that are close to 2011 census population which is used as the standard
population for age standardized rates using SFMS and GATS.
3
Web Table 2c: The 1998 and 2010 age standardized smoking prevalence for ages 60-69 years and 70+ years, by state and location
of residence.
States/ Regions
Total
1998 2010
60-69 years
Rural
1998 2010
Urban
1998 2010
Total
1998 2010
70+ years
Rural
1998 2010
Urban
1998 2010
Men
Himachal Pradesh
60.5
41.6
62.4
47.4
39.3
8.6
54.7
47.2
56.5
49.4
30.3
0.0
Punjab
10.3
21.6
10.6
25.6
9.6
13.6
8.6
12.2
9.3
16.5
6.6
7.1
Chandigarh
18.6
29.4
24.2
66.7
18.1
26.9
14.6
28.4
26.6
100
13.6
3.9
Haryana
62.6
52.2
72.7
60.6
34.3
46.0
54.8
56.1
64.5
66.8
27.7
16.9
Delhi
17.5
57.8
35.2
35.4
16.7
57.4
11.8
0.0
32.1
0.0
10.9
0.0
Rajasthan
55.0
30.2
59.3
35.8
40.9
18.8
44.6
30.2
50.2
33.3
30.0
42.4
Uttar Pradesh/ Uttaranchal
50.5
45.7
52.9
49.7
40.6
30.3
40.6
32.2
43.1
30.0
31.3
45.1
Bihar/ Jharkhand
42.1
24.4
42.4
25.5
40.6
17.5
33.3
24.8
33.9
24.8
29.2
25.6
Assam
62.9
33.8
65.9
34.9
46.5
35.7
55.3
33.3
58.0
36.4
41.5
0.0
West Bengal
53.2
42.8
59.5
38.7
41.9
48.9
33.4
28.0
39.7
35.3
24.8
16.9
Odisha
23.0
14.7
23.1
14.4
22.1
21.3
17.8
15.6
18.6
20.4
13.1
0.0
Madhya Pradesh/ Chhattisgarh
42.9
37.0
45.3
34.7
34.4
49.4
31.2
31.9
35.4
36.3
19.3
7.4
Gujarat
40.5
35.4
44.2
46.3
32.5
22.5
33.1
47.1
37.6
58.4
23.8
30.1
Maharashtra
19.0
20.2
23.2
24.5
12.7
15.3
13.3
16.9
17.0
21.1
8.4
7.9
Andhra Pradesh
44.8
51.8
48.2
57.7
32.2
36.0
34.3
39.8
37.5
40.7
22.5
37.4
Karnataka
36.0
26.0
38.5
31.1
31.6
18.4
27.0
45.6
30.1
56.6
22.0
16.5
Goa
34.5
10.9
41.5
14.7
27.9
5.0
26.5
3.6
29.8
5.3
23.2
0.0
Kerala
29.5
31.2
31.2
37.8
24.8
12.2
18.4
29.3
19.0
31.2
16.4
22.6
Tamil Nadu
19.9
24.5
20.9
30.5
18.4
19.0
11.4
29.2
12.1
41.6
10.5
16.2
North East
60.2
56.8
62.3
61.3
53.1
41.1
52.7
55.0
54.6
60.9
46.7
17.7
INDIA TOTAL
39.1
33.4
43.0
36.8
28.7
24.8
30.0
30.0
34.1
33.8
19.9
18.7
3.0
8.7
3.5
10.8
1.8
1.1
2.8
10.6
3.3
12.8
1.6
1.5
Women
INDIA TOTAL
4
Web Table 3: The 1998 and 2010 age standardized rates and age standardized rates ratios of smoking among men aged 15-69
years, by education level and type of product.
Smoke Type
Illiterate or no formal education
Less than 10th grade
10th grade and above
1998/2010
ASRR
1998/2010
ASRR
1998/2010
ASRR
15-29 years
13.9/22.1
1.6(1.1-2.0)
9.4/14.5
1.5(1.4-1.7)
4.9/7.5
1.5(1.3-1.7)
30-44years
46.5/39.9
0.9(0.8-0.9)
36.0/32.2
0.9(0.8-0.95)
25.5/20.1
0.8(0.7-0.9)
45-59years
51.4/47.9
0.9(0.9-1.0)
41.7/41.2
1.0(0.9-1.1)
30.1/23.1
0.8(0.7-0.9)
60-69years
45.1/40.9
0.9(0.8-1.0)
34.6/32.1
0.9(0.8-1.1)
22.9/20.2
0.9(0.6-1.1)
15-69years
33.9/35.4
1.0(1.0-1.1)
25.1/26.1
1.0(1.0-1.1)
17.8/15.2
0.9(0.8-0.9)
70+years
35.2/35.5
1.0(0.9-1.2)
24.2/28.9
1.2(1.0-1.4)
15.5/11.2
0.7(0.3-1.0)
15-29 years
1.6/10.8
6.8(2.9-9.8)
2.0/8.1
4.1(3.6-4.5)
2.0/6.2
3.1(2.6-3.4)
30-44years
4.3/10.7
2.5(2.1-2.8)
7.8/14.1
1.8(1.6-2.0)
12.5/14
1.1(1.0-1.2)
45-59years
3.7/11.8
3.2(2.4-3.8)
8.2/15.0
1.8(1.6-2.0)
15.3/14.7
1.0(0.8-1.1)
60-69years
2.2/9.3
4.2(3.0-5.1)
5.3/9.3
1.8(1.2-2.2)
9.2/11.8
1.3(0.9-1.6)
15-69years
2.9/10.4
3.6(3.0-4.0)
5.1/11.2
2.2(2.1-2.3)
8.5/10.6
1.3(1.2-1.3)
1.6/6.8
4.4(2.7-5.6)
3.2/8.4
2.7(1.6-3.5)
5.9/3.8
0.6(0.1-0.99)
15-29 years
10.9/14
1.3(0.9-1.6)
6.6/8.1
1.2(1.0-1.5)
2.4/1.9
0.8(0.5-0.99)
30-44years
37.2/33.1
0.9(0.8-1.0)
25.4/22.7
0.9(0.8-0.97)
11.0/7.8
0.7(0.6-0.8)
45-59years
40.2/38.7
1.0(0.9-1.1)
29.4/30.2
1.0(0.9-1.1)
12.2/11.1
0.9(0.7-1.1)
60-69years
32.9/33.4
1.0(0.8-1.2)
24.4/25.8
1.1(0.9-1.2)
10.4/11
1.0(0.5-1.5)
15-69years
26.6/27.9
1.0(1.0-1.1)
17.7/18.0
1.0(1.0-1.1)
7.8/6.1
0.8(0.7-0.9)
70+years
22.4/26.8
1.2(1.0-1.4)
15.9/21.1
1.3(1.0-1.6)
6.9/7.4
1.1(0.2-1.6)
Any Smoking
Cigarettes
70+years
Bidis
5
Web Figure 1: Age-standardized rate (ASR) of smoking among men by age group and product for 1998-2010 and number of smokers in 2015 (in millions) in
rural India.
Note: * ASRR=ASR GATS/ ASR SFMS (99% CI)
6
Web Figure 1: Age-standardized rate (ASR) of smoking among men by age group and product for 1998-2010 and number of smokers in 2015 (in millions) in
urban India.
Note: * ASRR=ASR GATS/ ASR SFMS (99% CI)
7