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The incontrovertible scientific evidence about tobacco use causing serious health consequences is
now accepted even by the tobacco industry. Research continues to enlarge the spectrum of diseases
caused by tobacco use among users as well as among nonusers exposed to secondhand tobacco smoke.
This review attempts to illustrate the greater risk to adverse health outcomes among the less educated
due to a greater prevalence of tobacco use among them.
Numerous surveys worldwide and in India show a greater prevalence of tobacco use among the less
educated and illiterate. In a large population based study in Mumbai, the odds ratios for any kind
of tobacco use among the illiterate as compared to the college educated were 7.4 for males and 20.3
for females after adjusting for age and occupation. School-dropouts are more likely to take up
tobacco use in childhood and adolescence. Student youth taught about the dangers of tobacco use in
school are less likely to initiate tobacco use. High tobacco use among the less educated and under
privileged affects them in multiple ways: (i) Tobacco users in such households, because of their
nicotine addiction, prefer spending a disproportionate amount of their meager income on tobacco
products, often curtailing essential expenditures for food, healthcare and education for the family.
(ii) Because of high tobacco use and other factors of disadvantage connected with low educational
status, they suffer more from the diseases and other health impacts caused by tobacco. This higher
morbidity results in high health care expenditures, which impoverish the family further.
(iii) Premature death caused by tobacco use in this under- privileged section often takes away the
major wage earner in the family, plunging it into even more hardship. Tobacco use is a terrible
scourge particularly of the less educated, globally and in India. Tobacco use, education and health
in a human population are inter-related in ways that make sufferings and deaths caused by tobacco
use even more tragic than normally realized. Tobacco use works against social and economic
development and should be appropriately addressed through health education and tobacco cessation
services particularly in the under priviledged, illiterate population.
Key words Cardiovascular diseases - chronic bronchitis - educational status - health care - India - morbidity - mortality neoplasms - pregnancy outcome - prevalence - risk - smokeless tobacco - smoking - tobacco use cessation
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Introduction
Scientific evidence of disease caused by tobacco
use has been piling up steadily since the mid 1960s.
Smoking is a major cause of cancer, especially of the
lung, larynx, oral cavity, pharynx and oesophagus, as
well as of cardiovascular diseases and chronic
obstructive pulmonary diseases1-3. Pregnant women who
smoke are more likely to have low birth weight babies
or still-births. Smokeless tobacco use in pregnancy also
increases the likelihood of such adverse outcomes4,5.
Smokeless tobacco use causes oral cancer, oesophageal
cancer (if chewed with betel quid), and contributes to
cardiovascular diseases3,6. A large body of evidence
exists for disease causation due to tobacco smoke in
the environment7.
A large follow up study of British doctors led
researchers to infer that half of all cigarette smokers
eventually die from smoking related diseases, about a
quarter of them in middle age8,9. The WHO estimates
that approximately 12 per cent of global deaths are due
to smoking about 5 million deaths10. Today even the
tobacco industry admits (on its websites) that tobacco
smoking is addictive and causes many serious diseases.
Awareness of these dangers of tobacco use is
increasing over time in the population worldwide, but
faster in more educated in populations11. The illiterate
have even less access to these facts, use tobacco and
suffer tobacco related disease in larger proportions.
International evidence
Tobacco use is much more common among the less
educated and less privileged sections of most societies.
This has been documented in many countries the world
over, including India, through national surveys and
surveys in localised populations12.
As a recent example, a cross-sectional study across
15 European countries in 19992000 on men and
women heart patients, aged 71 yr and above, showed
that the prevalence of current smoking was significantly
lower in men with secondary education compared to
those with only primary education and lower in men
with tertiary education compared to those with
secondary education alone13.
Prevalence studies in Nigeria, Malawi and Zambia
point to a greater vulnerability of poorer and less
educated people to smoking. However, some studies in
South Africa and Chad found better educated people
had higher smoking rates than the less educated. Thus,
(a)
291
(b)
Fig. 1a & b. Educational gradient for two types of tobacco use in the National Family Health Survey-2 in India (1998-1999). (a) Smoking
by years of education. (b) Chewing by years of education. Based on data from: Rani et al, 2003.
292
(a)
(b)
(c)
(d)
Fig. 2 (a-d). Educational gradients for use of different tobacco products, Mumbai. (a) Any tobacco use by education (Mumbai study).
(b) Cigarette smoking by education (Mumbai study). (c) Smokeless tobacco use by education. (d) Bidi smoking by education (Mumbai study).
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References
1.
2.
3.
4.
5.
6.
7.
8.
9.
297
articles/mi_m0EUB/is_n1_v10/ai_19309408/pg_1, accessed
on May 28, 2007.
12. Bobak M, Jha P, Nguyen S, Jarvis M. Poverty and smoking.
In: Jha P, Chaloupka F, editors. Tobacco control in developing
countries. Oxford: Oxford University Press; 2000 p. 41-61.
13. Mayer O, Imon J, Heidrich J, Cokkinos DV, De Bacquer D.
Educational level and risk profile of cardiac patients in the
EUROASPIRE II substudy. J Epidemiol Community Health
2004; 58 : 47-52.
14. Townsend L, Fisher AJ, Gilreath T and King G. A systematic
literature review of tobacco use among adults 15 years and
older in sub-Saharan Africa from 1900 to mid 2005. Drug
Alcohol Depend 2006; 84 : 14-27.
15. Kanjilal S, Gregg EW, Cheng YJ, Zhang P, Nelson DE, Mensah
G. Socioeconomic status and trends in disparities in 4 major
risk factors for cardiovascular disease among US adults, 19712002. Arch Intern Med 2006; 166 : 2348-55.
16. Giskes K, Kunst AE, Benach J, Borrell C, Costa G, Dahl E, et
al. Trends in smoking behaviour between 1985 and 2000 in
nine European countries by education. J Epidemiol Community
Health 2005; 59 : 395-401.
17. Yang G, Ma J, Chen A, Zhang Y, Samet JM, Taylor CE, et al.
Smoking cessation in China: findings from the 1996 national
prevalence survey. Tob Control 2001; 10 (Summer) : 170-4.
18. International Institute for Population Sciences (IIPS) and ORC
Macro. NFHS-2 National Family Health Survey 1998-1999;
2000. Mumbai: IIPS. p 41-5.
19. Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco
use in India: prevalence and predictors of smoking and
chewing in a national cross sectional household survey. Tob
Control 2003; 12 : 341. (abstract). Available from: http://
tobaccocontrol.bmj.com/cgi/reprint/12/4/e4
http://
www.tobaccocontrol.com/cgi/content/full/12/4/e4, accessed on
April 23, 2005.
20. Gupta PC. Survey of sociodemographic characteristics of
tobacco use among 99,598 individuals in Bombay, India using
handheld computers. Tob Control 1996 (Summer); 5 : 114-20.
21. Sorensen G, Gupta PC, Pednekar MS. Social disparities in
tobacco use in Mumbai, India: the roles of occupation,
education, and gender. Am J Public Health 2005; 95 :
1003-8.
22. Narayan KM, Chadha SL, Hanson RL, Tandon R, Shekhawat
S, Fernandes RJ, et al. Prevalence and patterns of smoking in
Delhi: cross sectional study. BMJ 1996; 312 : 1576-9.
23. Sen U. Tobacco use in Kolkata. Lifeline 2002; 8 : 7-9.
24. Chaudhry K, Prabhakar AK, Prabhakaran PS, Prasad A, Singh
K, Singh A. Prevalence of tobacco use in Karnataka and Uttar
Pradesh in India. Final report of the study by the Indian
Council of Medical Research and the WHO South East Asian
Regional Office, New Delhi 2001. Available from: http://
searo.who.int/EN/Section1174/section1462/pdfs/surv/
SentinelIndia2001.pdf.
25. Dreze J, Sen A. India - Economic development and social
opportunity. New Delhi: Oxford University Press; 1995 p. 47.
26. Gupta PC, Ray CS. Tobacco and youth in the South East Asian
region. Indian J Cancer 2002; 39 : 5-35.
298
40. Sinha DN, Reddy KS, Rahman K, Warren C, Jones NR, Asma
S. Linking global youth tobacco survey (GYTS) data to the
WHO framework convention on tobacco control: The case
for India. Indian J Publ Health 2006; 50 : 74-87.
41. Reddy SK, Gupta PC, editors. Report on tobacco control in
India. New Delhi: Ministry of Health and Family Welfare;
2004 p. 61-6.
42. National Sample Survey Organization. Consumption of some
important commodities in India, NSS 55th Round (19992000), New Delhi: Ministry of Statistics & Programme
Implementation, Government of India; 2000.
43. John, R. Crowding-out effect of tobacco expenditure and its
implications on intra-household resource allocation. Indira
Gandhi Institute of Development Research Working Paper
Series No. WP-2006-002. March, 2006. Available from: http:/
/www.igidr.ac.in/publicationlist.php?crsid=5.
44. Peters DH, Yazbeck AS, Sharma RR, Ramana GNV, Pritchett
LH, Wagstaff A. Better health systems for Indias poor:
Findings, analysis, and options. New Delhi: The World Bank,
2002. Human Development Network, Health, Nutrition, and
Population Series. Available from: http://www1.worldbank.
org/publications/pdfs/15029overview.pdf, accessed on
November 17, 2006.
45. Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and
mortality from tuberculosis and other diseases in India:
retrospective study of 43000 adult male deaths and 35000
controls. Lancet 2003; 362 : 507-15.
46. Gupta PC, Pednekar MS, Parkin DM, Sankaranarayanan R.
Tobacco associated mortality in Mumbai (Bombay) India.
Results of the Bombay Cohort Study. Int J Epidemiol 2005;
34 : 1395-402.
47. Gupta R, Gupta VP, Ahluwalia NS. Educational status,
coronary heart disease, and coronary risk factor prevalence in
a rural population of India. BMJ 1994; 309 : 1332-6.
48. Jindal SK, Aggarwal AN, Chaudhry K, Chhabra SK, Souza
GA, Gupta D, et al. A multicentric study on epidemiology of
chronic obstructive pulmonary disease and its relationship with
tobacco smoking and environmental tobacco smoke exposure.
Indian J Chest Dis Allied Sci 2006; 48 : 23-9.
49. Chhabra SK, Rajpal S, Gupta R. Patterns of smoking in Delhi
and comparison of chronic respiratory morbidity among beedi
and cigarette smokers. Indian J Chest Dis Allied Sci 2001;
43 : 19-26.
50. Gupta D, Aggarwal AN, Kumar S, Jindal SK. Smoking
increases risk of pulmonary tuberculosis. J Environ Med 2001;
3 : 65-9.
51. Rao DN, Ganesh B, Rao RS, Desai PB. Risk assessment of
tobacco, alcohol and diet in oral cancer - a case-control study.
Int J Cancer 1994; 58 : 469-73.
52. Rao DN, Desai PB, Ganesh B. Alcohol as an additional risk
factor in laryngopharyngeal cancer in Mumbai - a case-control
study. Cancer Detect Prev 1999; 23 : 37-44.
53. Gupta D, Boffetta P, Gaborieu V, Jindal SK. Risk factors of
lung cancer in Chandigarh. Indian J Med Res 2001; 113 :
142-50.
54. Sorensen G, Barbeau EM. Integrating occupational health,
safety and worksite health promotion: opportunities for
research and practice. Med Lav 2006; 97 : 240-57.
299
66. Patterson F, Lerman C, Kaufmann VG, Neuner GA, AudrainMcGovern J. Cigarette smoking practices among American
college students: review and future directions. J Am Coll
Health 2004; 52 : 203-10.
68. Aghi MB, Gupta PC, Bhonsle RB, Murti PR. Communication
strategies for intervening in the tobacco habits of rural
populations in India. In: Gupta PC, Hamner JE III, Murti PR,
editors. Control of tobacco-related cancers and other diseases.
Proceedings of an International Symposium; January 15-19,
1990; TIFR, Mumbai, India. Mumbai: Oxford University
Press; 1992 p. 303-6.
69. Gupta PC, Mehta FS, Pindborg JJ, Bhonsle RB, Murti PR,
Daftary DK, et al. Primary prevention trial of oral cancer in
India: a 10-year follow-up study. J Oral Pathol Med 1992;
21 : 433-9.
70. International Labour Office. Making ends meet: Bidi workers
in India today - A study of four States, Working paper of the
Sectoral Activities Programme. Geneva: International Labour
Office; 2001.
Reprint requests: Dr Prakash C. Gupta, Director, Healis - Sekhsaria Institute for Public Health, 601/B Great Eastern Chambers
Plot no. 28, Sector 11, CBD Belapur, Navi Mumbai 400614, India
e-mail: pcgupta@healis.org