INTRODUCTION

Tobacco use in either smoking or smokeless forms is a major public health challenge with 80% of users living in low- and middle-income countries (LMICs). Smokeless tobacco (SLT), defined as a tobacco containing product that is consumed through chewing in the mouth, sniffing, or as a dissolvable has over 356 million users globally with 232 million in India and Bangladesh^1,2. SLT is a nicotine containing addicting substance with other carcinogenic chemicals that increases the risk of cancers of the head and neck, especially mouth and throat, and is independently associated with incidence of various cardiovascular diseases^3,4. As per the Global Burden of Disease 2019 estimates, SLT is attributed to cause over 8.6 million DALYs and about 350000 deaths annually⁵.

In LMICs, with most tobacco smokers being men and the prevalence of tobacco smoking being comparatively very low in women, there is a lack of policy attention and neglect of the impact of SLT use among women⁶. According to the Global Adult Tobacco Survey (GATS)-2 (2015–2016), India has 29.6% male and 12.1% female SLT users, signifying high prevalence in both genders compared to tobacco smoking in 19% men and only 2% women⁷. Women might have a higher risk of SLT addiction especially due to earlier initiation during adolescence and is also linked to a practice employed for suppression of hunger⁸. Furthermore, there is evidence to suggest that female SLT users have higher odds of developing oral cancer compared with males. SLT use during pregnancy is also linked to impairment of fetal lung and brain development, adverse maternal and infant nutritional outcomes, preterm delivery, low birth weight, and stillbirth^9-12.

Evidence from the GATS is also indicative of a declining trend in smokeless tobacco use amongst women from 18.4% (2009–2010) to 12.8% (2016–2017). According to the National Family Health Survey-4 (2015–2016), a greater proportion of women in India have also reported an absence of intention to quit and also higher failure to quit SLT use compared to males¹³. Women in India are also less likely to notice health warnings related to tobacco including SLT use, suggestive of adverse social determinants such as reduced literacy contributing to higher risk of tobacco and SLT addiction compared to men. Consequently, three fifths of deaths attributable to SLT use occur in women¹⁴. In some cases, women may also lack confidence to access tobacco cessation services due to the perceived societal stigma linked to the phenomenon.

It is important to identify the prevalence and predictors of tobacco use through disaggregated data amongst women in India, particularly in the more vulnerable older population with prolonged addiction who, in the absence of interventions to promote cessation, have increased risk of developing cancer and heart disease due to the additive effect of multiple synergistic risk factors with tobacco¹⁴. However, there exists limited evidence on tobacco use characteristics by women in India. The evidence of tobacco use from demographic and health surveillance data is restricted to younger and middle-aged women who have comparatively improved educational parameters which limits generalizability of those findings to older women¹³. Consequently, the present study was conducted with the objective of ascertaining the prevalence and sociodemographic determinants of tobacco (smoking and SLT) use and the predictors of quit in SLT-using older women in India from analysis of nationally representative health survey data.

METHODS

RESULTS

The SAGE-2 (2015) dataset consisted of 4946 females, with a mean age of 54.62 years (SD=14.42). The mean age of initiation of smoking in women aged ≥50 years was 27.57 years (SD=21.74) and for SLT it was 28.76 years (SD=24.28). Table 1 gives the sociodemographic characteristics in the study sample consisting of females aged ≥50 years (n=3781).

In Table 2, it can be seen that the prevalence of tobacco ever use, in any form, among women decreased from 34.17% (n=3254; 95% CI: 31.78–36.64) (SAGE-1; 2007) to 18.17% (n=3772; 95% CI: 16.63–19.82) (SAGE-2; 2015). The prevalence of current tobacco product use in any form was 9.89% (n=352; 95% CI: 8.74–11.17). Overall prevalence of current tobacco smoking was 9.42% (n=331; 95% CI: 8.29–10.69) and the mean duration of usage among current tobacco users was 18.67 years (SD=15.96). Overall prevalence of SLT usage among women aged ≥50 years was estimated as 12.3% (n=454; 95% CI: 10.99–13.72) and the mean duration of usage among current SLT users was 22.93 years (SD=16.83).

The prevalence of past SLT use in the women aged ≥50 years was 1.19% for daily but not current user (n=43; 95% CI: 0.84–1.69), while 98.67% women reported as never having initiated tobacco use (n=3731; 95% CI: 98.16–99.04) (Table 2). Among all women aged ≥50 years, 6.59% (n=267) were only SLT users, 3.72% (n=144) were only tobacco smokers, and 5.69% (n=187) were dual users. Within the tobacco users (n=598), 23.26% (n=144; 95% CI: 19.06–28.06) were only tobacco smokers, 41.17% (n=267; 95% CI: 36.11–46.42) were only SLT users, and 35.57% (n=187; 95% CI: 30.87–40.58) were dual users.

Table 3 gives the distribution of factors associated with smoking status among women aged ≥50 years. On adjusted analysis, increasing BMI and wealth quintiles were observed as having significantly lower odds of smoking in women. Furthermore, women belonging to ‘Other’ religions had significantly higher odds of smoking compared to Hindu women (AOR=1.95; 95% CI: 1.11– 3.44).

On bivariate analysis, age, BMI, ethnicity, religion, and quintiles of wealth score, were significantly associated (p<0.05) with SLT usage (Table 4). In the multivariate logistic regression analysis, increasing age, BMI, ethnic group, religion, and quintiles of wealth score, were significantly associated (p<0.05) with SLT usage. Elderly women (aged ≥70 years) had higher odds of using SLT (AOR=1.46; 95% CI: 1.05–2.03), while increasing BMI was negatively associated with SLT usage (AOR=0.53; 95% CI: 0.31–0.90). With reference to scheduled tribes, scheduled caste women had higher odds of using SLT (AOR=1.20; 95% CI: 0.77–1.86). Muslim women had higher odds of using SLT compared to the Hindu women (AOR=1.86; 95% CI: 1.24–2.69). There were 7.62% (n=37; 95% CI: 5.23–10.99) women who reported a successful quit after initiation with SLT (Table 5). The adjusted odds of quitting SLT in women belonging to the scheduled caste ethnicity were 0.70 times less (95% CI: 0.09–5.81) compared to the scheduled tribe ethnicity group.

DISCUSSION

The present study evaluated the prevalence and sociodemographic determinants of tobacco use patterns and predictors of quit among older women aged ≥50 years. Age, BMI, lower wealth quintiles, and ethnicity were found to be the determinants associated with tobacco smoking in the study sample, in line with the results of prior studies^12,13. However, the prevalence of tobacco smoking in women aged ≥50 years in this analysis from the SAGE survey (9.42%) was nearly two-fold higher compared to observations from the GATS survey data (5.14%), suggesting the need for repeated surveys to validate the extent of this public health problem in India, especially in women¹².

We found that the majority of tobacco users among females aged ≥60 years were SLT users, a finding similar to a study based on GATS I and II¹⁵. On bivariate analysis, age, BMI, ethnicity, quintiles of wealth index, and religious denomination were significantly associated with SLT usage. These findings agree with studies conducted in other LMICs such as Pakistan¹⁶, Bangladesh¹⁷ and Nepal¹⁸. SLT usage is often initiated at an early age when children are exposed and normalized to it and are frequently involved in its purchase for family members¹⁹. In this study, SLT use was found to have significantly declined among women, a finding which also corroborates the trend from GATS-1 and GATS-2¹². Similar to previous studies, age was found to be directly associated with SLT use, whereas BMI was found to have an inverse relation in our analysis^15,20.

Furthermore, we observed that women belonging to the poorest section of society (first quintile) had higher odds of using SLT, a finding similar to that observed in the GATS 2 survey²¹. In this study, spoken language did not have a statistically significant association with SLT use unlike a previous study suggesting that the association was likely to have been coincidental²².

Nevertheless, our study findings indicate that ethnicity is possibly linked with SLT use in India as the scheduled caste ethnicity women had significantly higher odds of consuming SLT compared to women from other caste groups. A study based on the second round of the Indian National Family Health Survey (NFHS-2; 1998–1999) had also reported that tobacco consumption was significantly more prevalent among scheduled caste populations, signifying their persistent vulnerability¹³. Prior evidence also suggests that women belonging to socioeconomically disadvantaged populations employed in hard labor activities often use tobacco to suppress hunger^8,23 and reduce perceived stress. Further, our finding suggests that Muslim women were more likely to use SLT, a finding consistent with evidence from NFHS-2¹³ and Bangladesh²⁴.

The present study findings suggest that a very small proportion of older women who are SLT users in India successfully quit tobacco. Improving the awareness of the harmful effects of tobacco and especially SLT use among women is necessary to reduce its initiation and persistence²⁵. Evidence from GATS 2 had shown that nearly half of the women in India (45.3%) fail to take notice of health warnings on SLT product packages²⁶. Furthermore, the use of quitline/helpline/direct counselling is very low overall, due to difficult accessibility, lack of social support, and associated stigma²⁷. Our study findings suggest the need for enhanced tobacco use surveillance and targeted interventions for promoting tobacco cessation, especially SLT, amongst older women users who experience the double impact of adverse social determinants such as lower SES, and belonging to marginalized communities that contribute to reduced access to tobacco quit services. Future research should also explore the evolving dynamics of determinants and cultural factors shaping tobacco use, since a nuanced understanding of the motivations for tobacco use in this vulnerable population can inform the design of tailored interventions which are effective in reducing tobacco consumption among women in India.

CONCLUSIONS

Nearly one in five older women were found to use tobacco in some form. The higher prevalence of tobacco smoking and smokeless tobacco use compared to GATS data calls for continuous surveillance and focused public health efforts. Furthermore, quit rates in female SLT users continue to be very low (nearly one in ten) suggesting the need for strengthening access, availability, and affordability of tobacco cessation services to promote successful quitting behavior.