This study gives a comprehensive picture of the prevalence and determinants of tobacco use among Indian men aged 15–54 years using a recent national survey. Almost one in every two men (45.5%) used tobacco in 2015–2016 in India. Age, lower education, occupation, region, alcohol consumption, separated/divorced/widowed men, and richest economic status substantially had a stable association with all four groups of tobacco use described in this study. The magnitude and correlation of other selected variables differ according to the forms of tobacco use described below. The findings of the studies from India [9], Nepal [18], Afghanistan [19], and Ethiopia [20] are coherent with the finding of our study.
Prevalence of different forms of tobacco use
Around one-fourth of men use smoking (24.6%) and one-third used SLT (29.1%) while one in every ten men used both smoked and SLT (8.4%). The prevalence of all groups of tobacco use is decreasing in India in the last two decades [11, 13]. The prevalence of smoking (27.3%), SLT (40.2%), and any form of tobacco (52.3%) was higher in the neighboring country, Nepal [18]. Our study found that the prevalence of smoking was lower than the proportion of SLT use. The result is consistent with the finding of other studies conducted in India [13, 21].
Tobacco use was more prevalent among men in the older group, lower wealth status and education, manual occupation, separated/divorced/widowed, alcohol consumer, residents of the rural area and north-east region, and less access to information. Studies conducted in India found that increasing age, living in rural areas, low education, and economic status increased tobacco use [11, 13, 22]. Khanal et al. [22] also found that tobacco use was more prevalent among men who have less access to information and have manual working status. The residence of the north-east region was more prevalent to being a tobacco user also as reported by another Indian study [13]. Smoking was more common among respondents from Muslim religion and ethnic groups having no caste/tribe. The finding is coherent with an Indian study [11].
Factors associated with tobacco use
The strength of the association of consuming alcohol and residing in the north-east region with tobacco use was stronger than other variables. The magnitude of alcohol consumption was stronger for smoking than smokeless tobacco use. Tang et al. [23] also showed a similar finding in Ethiopia. People who consume alcohol more tend to smoke more [15]. Similarly, smokers have 2.7 times more risk to be alcohol users than men who do not smoke. Control programs of alcohol abuse should not be isolated from the tobacco control program [24]. A higher association of tobacco use with the north-east region is due to the significant effects of peers and cultural acceptance of tobacco using in the north-east region [25].
The men who were engaged in manual work were more prone to be a tobacco user. High working hours and working conditions would be a possible cause for more tobacco use among this group [26]. On the other hand, people who engaged in professional work tend to avoid tobacco use in some office settings [15]. Increasing age positively correlated with smoking, any tobacco, and dual-use. Similar findings were reported by studies from India [15] and Ethiopia [27, 28]. The longer period for the trial of tobacco consumption is one reason for higher users among elders [28].
Higher education and economic status had a strong protective effect on tobacco use. Recent studies in India also reported that higher education and wealth status correlated with tobacco use [9, 12]. Highly educated men usually have better self-efficacy, healthy behavior, and high access to information [15]. Men with poor wealth quintiles have a lack of awareness of tobacco hazards, and the economic burdens and stress trigger them to use tobacco [29]. Additionally, respondents who are separated/divorced/widowed during the study period were more prone to be a tobacco user. Our findings are consistent with a study performed in Ethiopia [20, 22].
Ethnicity, religion, and the living urban area had a significant association with smoking [20]. Men from no caste/tribe and other religious groups were less likely SLT users whereas the association of tribe ethnic group, Muslim religion, and living in urban with SLT use were not significant. Living in urban was not associated with SLT in Nepal [22] and in India [11].
In access to information, watching television and listening to radio associated with smoking while reading newspaper had an insignificant correlation. A similar result was demonstrated by a recent study based on a national representative study in Afghanistan [19]. Reading newspapers and listening to the radio at least once a week and almost every day had a weaker protective effect on using any tobacco and SLT while the correlation of watching television with SLT use was found insignificant. A study conducted in Nepal reported reading newspapers or magazines protect from being SLT users [22]. Specific health messages should be disseminated through specific media as the finding shows that association varied between forms of tobacco use and type of media.
Public health implication
The burden of tobacco use is a great public health problem in India. Policymakers need to develop innovative and cost-effective strategies to mitigate the burden of tobacco use. One important policy implication of our findings is that the high-risk group, the men from lower wealth status, less education, north-east region, and manual working status should be targeted to reduce tobacco use. Increasing the Social Behavior Change Communication (SBCC) and awareness campaigns about the danger of tobacco use needs to be implemented aiming to spread messages and being behavior change among tobacco users. All types of national, local, and social media should be used to disseminate the messages. As alcohol consumption triggers tobacco use, anti-smoking campaigns should also focus on reducing alcohol abuse. Finally, long-term success in curbing the burden of smoking will require political commitment including harmonized legal provisions, such as reducing tobacco marketing, formal education about the dangers of tobacco use, progressive tax, packaging, and labeling of tobacco products and price strategies.
Strengths and limitations
We analyzed nationally representative data with a high response rate. The results of this study are generalizable. We applied sample weight, cluster effect, and complex sampling during our analysis, and collected 95% CI with point estimates. These actions increase the precision of the study findings. The main limitation of this study is the survey, NFHS-4, which is focused on maternal and child health and reproductive health in women, and the target population was limited to aged 15–54 years in men. Our finding shows the prevalence and association of tobacco use in men increase with age. The exclusion of elderly men may affect the finding we found in this study. The prevalence data collected by self-reporting generally underestimated as tobacco using sometimes correlated with a social stigma. The cross-sectional design of this study limits from drawing causal inferences.