Original Article

Tobacco Smoking in India: Prevalence, Quit-rates and

Respiratory Morbidity
S.K. Jindal1, A.N. Aggarwal1, K. Chaudhry2, S.K. Chhabra3, G.A. D’Souza4, D. Gupta1,
S.K. Katiyar5, R. Kumar1, B. Shah2, V.K. Vijayan3 for Asthma Epidemiology Study Group

Postgraduate Institute of Medical Education and Research1, Chandigarh; Indian Council of Medical Research2,
New Delhi; Vallabhbhai Patel Chest Institute3, Delhi; St. John’s Medical College Hospital4 Bangalore;
G.S.V.M. Medical College5, Kanpur, India

ABSTRACT

Background. Population prevalence of tobacco smoking especially with reference to detailed habits such as the amount
smoked, the smoking forms, quit-rates and relationship with demographic variables were studied at four different centres
in India along with the study on epidemiology of asthma and chronic obstructive pulmonary disease.
Methods. The study population included adults of over 15 years of age selected with two-stage stratified random sample
design. A specifically designed questionnaire was used for the study.
Results. There were 11496 (15.6%) ever smokers in the study sample of 73605 subjects. Among 37682 males, 10756 (28.5%)
were ever smokers and among 35923 females, 740 (2.1%) were ever smokers. Bidi was the commonest form of smoking, more
so in the rural areas. The mean number of cigarettes/bidis smoked per day was 14 (± 11.5) and the mean age of starting
smoking was 20.5 (± 20.0) years. Increasing age, low socio-economic status and rural residence were important factors
associated with smoking. Vigorous anti-tobacco measures under the tobacco control programmes yielded only a quit-rate
of 10 percent. Nearly 14% of ever smokers had some respiratory symptoms.
Conclusions. A substantial proportion of population in India has current or past smoking habit with higher prevalence
among males than females. The quit-rates have been low in spite of the various anti-tobacco measures. There is a significant
respiratory morbidity associated with smoking. [Indian J Chest Dis Allied Sci 2006; 48: 37-42]

Key words: Smoking, Cigarettes, Bidis, Hookah, Respiratory morbidity, Population prevalence.

INTRODUCTION on the type of smoking forms, amount smoked, quit-

rates and relationship with different demographic
variables is relatively small. A multicentric study was
Tobacco use including both the smoking and the
undertaken to investigate the epidemiology of chronic
nonsmoking forms of tobacco is common in India. The
airway obstruction such as chronic obstructive
few reports of tobacco use in different population
pulmonary disease (COPD) and bronchial asthma in the
groups report its prevalence from about 15% to over
adult population 13. The present report provides
50% among men 1-7. Differences in its prevalence are
information on the population prevalence of smoking
rather wide for the nonsmoking forms. Tobacco
habits at four different centres studied with the help of
smoking in most parts of India except Punjab,
question items included in the questionnaire for the
Maharashtra and Sikkim is reported in about one fourth
above mentioned study.
to half of adult men of over 15 years of age 8. Amongst
women, smoking was more common in the North
Eastern states, Jammu & Kashmir and Bihar, while most MATERIAL AND METHODS
other parts of India had prevalence rates of about 4
percent or less 8. In other reports, ever smoking among The study reported here formed an essential component
the school going youth of 13- 15 years age, studied as a of the comprehensive report on epidemiology of asthma
part of the Global Youth Tobacco Survey (GYTS) study and COPD 13. Information on smoking habits,
was reported on an average in upto about 10 percent demographic and exposure variables was collected with
individuals9-12. the help of a single, pre-validated respiratory symptom
All these reports clearly indicate a higher prevalence questionnaire at Bangalore, Chandigarh, Delhi and
of tobacco smoking in adult men. Detailed information Kanpur employing a two-stage stratified sampling
[Received: September 29, 2005; accepted: October 28, 2005]
Correspondence and reprint requests: Dr S.K. Jindal, Professor and Head, Department of Pulmonary Medicine, Postgraduate
Institute of Medical Education and Research, Chandigarh-160012, India; Tele.: 91-0172-2756821; Telefax: 91-0172-2745959;
E-mail: skjindal@indiachest.org.
38 Smoking in India S.K. Jindal et al

design. Both rural and urban samples were studied with
a village or an urban locality as the first stage unit and
a household as the second stage unit. A specifically
written computer programme using the software Epi
info (V.6) which operated in DOS mode, was used for
analysis.
RESULTS
The study population of 73605 in total consisted of
37682 male and 35923 female subjects of over 15 years of
age. The distribution of subjects from each centre for
both the urban and the rural populations showed a little
higher preponderance of males except from Bangalore
where there was a larger number of female subjects of
urban residence (Table 1).
Ever smoking habit was present in 28.5% of men and
2.1% of women (Table 2). In spite of some differences
between the urban and the rural populations, the
overall prevalences were similar at all the four centres;
the lowest was reported form Kanpur (22%) and the
highest from Bangalore (33.6%) amongst men (Table 2).
Smoking was seen in 3.1% and 4.2% of women at
Chandigarh and Delhi respectively, while only 1% at
Kanpur and very few (only two ) at Bangalore had
reported the smoking history (Table 2).
Tobacco smoking was further analysed for the type
of smoking product and the amount of smoking.
Considering together the data from all the four centres,
cigarettes were smoked by 47.5% of urban and 12.5% in
rural smokers while bidis were smoked by 51.7% and
81.2% of urban and rural smokers respectively (Table 3).
The rest of the smokers smoked hookah alone or along
with other smoking products. The average number of
cigarettes/bidis smoked daily were similar in the rural
and urban smokers i.e. 15.0 and 12.4 respectively (Table
3). Hookah smoking could not be quantified on the basis
of numbers/day in the absence of a standard unit for a
hookah smoke. Interestingly, the mean age of starting
smoking was similar in both rural and urban subjects,
i.e. 20.2 and 21.0 years respectively (Table 3).
Differences in the smoking prevalence on the basis of
different variables were assessed by calculation of
crude and adjusted odds ratio (OR) for different
smoking products (Table 4). Both the crude and the
adjusted ORs for smoking any product were the highest
for the male sex. Other important variables important
for smoking were an increasing age, rural (or mixed)
residence and lower socio-economic status (Table 4).
The data on subjects who had quit smoking in the
past were analysed separately. Of 11496 ever smokers,
about 10 percent had quit in the past; 928(8.1%) for more
than 1 year and 153(1.3%) for less than 1 year (Table 5).
The important variables favouring abstinence from
smoking for more than a year were the increase in age
and a higher socio-economic status, male sex, and
presence of respiratory symptoms (Table 6). The ORs
were higher for Bangalore and Chandigarh versus Delhi
or Kanpur.

Table 1. Centre-wise distribution of study population categorised according to the gender and current residence
Urban Rural Total Total
Male Female Male Female Male Female
Bangalore 4527 4800 4111 4003 8638 8803 17441
Chandigarh 5717 5638 5333 4976 11050 10614 21664
Delhi 4033 3927 3933 3749 7966 7676 15642
Kanpur 6107 5552 3921 3278 10028 8830 18858
Total 20384 19917 17298 16006 37682 35923 73605

Table 2. Distribution of prevalence of smoking habit (current or former) in men and women respectively at the four centres
Men Women Total
Chandigarh Rural 2159 (40.5%) 275 (5.5%) 2434 (23.6%)
Urban 1144 (20.0%) 54 (1.0%) 1198 (10.6%)
Total 3303 (29.9%) 329 (3.1%) 3632 (16.8%)
Delhi Rural 1629 (41.4%) 280 (7.5%) 1909 (24.9%)
Urban 720 (17.9%) 42 (1.1%) 762 (9.6%)
Total 2349 (29.5%) 322 (4.2%) 2671 (17.1%)
Kanpur Rural 1032 (26.3%) 52 (1.6%) 1084 (15.1%)
Urban 1170 (19.2%) 36 (.6%) 1206 (10.3%)
Total 2202 (22.0%) 88 (1.0%) 2290 (12.1%)
Bangalore Rural 1427 (34.7%) 0 (.0%) 1427 (17.6%)
Urban 1475 (32.6%) 1 (.0%) 1476 (15.8%)
Total 2902 (33.6%) 1 (.0%) 2903 (16.6%)
Total Rural 6247 (36.1%) 607 (3.8%) 6854 (20.6%)
Urban 4509 (22.1%) 133 (0.7%) 4642 (11.5%)
Total 10756 (28.5%) 740 (2.1%) 11496 (15.6%)
 Table 3. Distribution of smokers with the type of product used, number of cigarettes/bidis smoked per day and the age of starting smoking
(at the 4 centres combined)
Rural Urban Total
2006; Vol. 48

Type of smoking product

Cigarettes 857 (12.5%) 2204 (47.5%) 3061 (26.6%)
Bidis 5568 (81.2%) 2402 (51.7%) 7970 (69.3%)
Hookah and others 429 (6.3%) 36 (0.8%) 465 (4.0%)
No. smoked per day
Mean 15.0 12.4 14.0
S.D 12.0 10.7 11.5
Median 12.0 10.0 12.0
Age of starting smoking (year)
Mean 20.2 21.0 20.5
S.D. 8.4 7.3 20.0
Median 20.0 20.0 20.0

Table 4. Crude and adjusted odds ratio (with 95% confidence intervals) of smoking in relation to various factors
Cigarette Smoking Bidi Smoking Any Tobacco Smoking
Crude odds ratio Adjusted odds ratio Crude odds ratio Adjusted odds ratio Crude odds ratio Adjusted odds ratio
Centre
Chandigarh* 1.000 1.000 1.000 1.000 1.000 1.000
Delhi 0.735 (0.658-0.822) 0.675 (0.600-0.761) 1.047 (0.983-1.116) 0.781 (0.722-0.844) 1.022 (0.968-1.080) 0.817 (0.764-0.874)
Kanpur 0.634 (0.569-0.706) 0.593 (0.523-0.673) 0.747 (0.700-0.797) 0.384 (0.351-0.420) 0.686 (0.649-0.726) 0.446 (0.413-0.481)
Bangalore 1.455 (1.329-1.592) 1.876 (1.695-2.076) 0.889 (0.834-0.948) 0.724 (0.668-0.784) 0.991 (0.940-1.046) 0.946 (0.885-1.011)
Usual residence
Urban* 1.000 1.000 1.000 1.000 1.000 1.000
Rural 0.601 (0.556-0.650) 0.632 (0.580-0.688) 2.979 (2.831-3.135) 3.592 (3.383-3.814) 1.999 (1.918-2.083) 2.243 (2.135-2.356)
Mixed 1.510 (1.239-1.839) 1.029 (0.821-1.289) 1.213 (0.990-1.485) 1.517 (1.201-1.916) 1.342 (1.159-1.554) 1.445 (1.212-1.722)
Gender
Female* 1.000 1.000 1.000 1.000 1.000 1.000
Male 70.116 (53.803-91.375) 83.269 (63.846-108.601) 18.954 (17.309-20.755) 27.499 (25.007-30.238) 18.992 (17.600-20.495) 25.882 (23.909-28.017)
Age
15-24 years* 1.000 1.000 1.000 1.000 1.000 1.000
The Indian Journal of Chest Diseases & Allied Sciences

25-34 years 4.134 (3.543-4.823) 4.570 (3.906-5.346) 6.286 (5.561-7.105) 7.147 (6.297-8.112) 5.431 (4.932-5.981) 6.068 (5.491-6.707)
35-44 years 6.133 (5.259-7.153) 7.685 (6.565-8.996) 11.087 (9.824-12.512) 15.553 (13.704-17.652) 9.189 (8.351-10.112) 12.154 (10.993-13.438)
45-54 years 8.559 (7.330-9.994) 11.041 (9.407-12.960) 15.348 (13.585-17.339) 25.974 (22.816-29.569) 12.817 (11.635-14.120) 19.292 (17.400-2 1.390)
55-64 years 8.183 (6.908-9.693) 12.142 (10.171-14.494) 16.762 (14.747-19.053) 31.316 (27.255-35.981) 14.073 (12.700-15.594) 23.928 (21.390-26.767)
65-74 years 8.530 (7.062-10.304) 12.958 (10.618-15.813) 19.374 (16.903-22.207) 33.641 (28.926-39.124) 16.841 (15.081-18.805) 26.747 (23.647-30.255)
>=75 years 6.675 (5.108-8.722) 8.717 (6.586-11.536) 16.639 (14.013-19.757) 23.306 (19.186-28.331) 16.858 (14.690-19.346) 21.981 (18.775-25.736)
Socio-economic
Status
High* 1.000 1.000 1.000 1.000 1.000 1.000
Medium 0.856 (07.758-0.967) 1.281 (1.123-1.463) 3.392 (2.894-3.977) 3.827 (3.234-4.529) 1.709 (1.555-1.879) 2.101 (1.889-2.336)
Low 0.515 (0.450-0.590) 1.151 (0.986-1.344) 5.125 (4.369-6.011) 11.138 (9.365-13.247) 2.002 (1.817-2.205) 4.161 (3.717-4.658)
39

*Reference category.
40 Smoking in India S.K. Jindal et al

Table 5. Current smoking habit among ever smokers and those who had quit smoking
Men Women Total
Current Quit Smoking Current Quit Smoking Current Quit Smoking
<1 year >1 year <1 year >1 year < 1 year >1 year

Chandigarh Rural 1990 (92.2%) 27 (1.3%) 142 (6.6%) 247 (89.8%) 3 (1.1%) 25 (9.1%) 2237 (91.9%) 30 (1.2%) 167 (6.9%)
Urban 965 (84.4%) 21 (1.8%) 158 (13.8%) 46 (85.2%) 2 (3.7%) 6 (11.1%) 1011 (84.4%) 23 (1.9%) 164 (13.7%)
Total 2955 (89.5%) 48 (1.5%) 300 (9.1%) 293 (89.1%) 5 (1.5%) 31 (9.4%) 3248 (89.4%) 53 (1.5%) 331 (9.1%)
Delhi Rural 1528 (93.8%) 23 (1.4%) 78 (4.8%) 262 (93.6%) 2 (.7%) 16 (5.7%) 1790 (93.8%) 25 (1.3%) 94 (4.9%)
Urban 668 (92.8%) 9 (1.3%) 43 (6.0%) 39 (92.9%) 1 (2.4%) 2 (4.8%) 707 (92.8%) 10 (1.3%) 45 (5.9%)
Total 2196 (93.5%) 32 (1.4%) 121 (5.2%) 301 (93.5%) 3 (.9%) 18 (5.6%) 2497 (93.5%) 35 (1.3%) 139 (5.2%)
Kanpur Rural 976 (94.6%) 10 (1.0%) 46 (4.5%) 49 (94.2%) 0 (.0%) 3 (5.8%) 1025 (94.6%) 10 (.9%) 49 (4.5%)
Urban 1053 (90.0%) 23 (2.0%) 94 (8.0%) 32 (88.9%) 2 (5.6%) 2 (5.6%) 1085 (90.0%) 25 (2.1%) 96 (8.0%)
Total 2029 (92.1%) 33 (1.5%) 140 (6.4%) 81 (92.0%) 2 (2.3%) 5 (5.7%) 2110 (92.1%) 35 (1.5%) 145 (6.3%)
Bangalore Rural 1260 (88.3%) 10 (.7%) 157 (11.0%) 0 (.0%) 0 (.0%) 0 (.0%) 1260 (88.3%) 10 (.7%) 157 (11.0%)
Urban 1299 (88.1%) 20 (1.4%) 156 (10.6%) 1 (100.0%) 0 (.0%) 0 (.0%) 1300 (88.1%) 20 (1.4%) 156 (10.6%)
Total 2559 (88.2%) 30 (1.0%) 313 (10.8%) 1 (100.0%) 0 (.0%) 0 (.0%) 2560 (88.2%) 30 (1.0%) 313 (10.8%)

Total Rural 5754 (92.1%) 70 (1.1%) 423 (6.8%) 558 (91.9%) 5 (.8%) 44 (7.2%) 6312 (92.1%) 75 (1.1%) 467 (6.8%)
Urban 3985 (88.4%) 73 (1.6%) 451 (10.0%) 118 (88.7%) 5 (3.8%) 10 (7.5%) 4103 (88.4%) 78 (1.7%) 461 (9.9%)
Total 9739 (90.5%) 143 (1.3%) 874 (8.1%) 676 (91.4%) 10 (1.4%) 54 (7.3%) 10415 (90.6%) 153 (1.3%) 928 (8.1%)

Table 6. Crude and adjusted odds ratio (with 95% confidence in never smokers, but the symptoms in the other two
intervals) of having quit smoking for more than a year, in groups were similar to those amongst the never
relation to various factors
smokers (Table 7).
Crude Odds Ratio Adjusted Odds Ratio
Centre DISCUSSION
Chandigarh* 1.000 1.000
Delhi 0.547 (0.446-0.672) 0.476 (0.384-0.590)
Kanpur 0.674 (0.551-0.826) 0.718 (0.565-0.914) The present study conducted at four different centres in
Bangalore 1.205 (1.024-1.418) 1.085 (0.905-1.302) India primarily to look into the population prevalence
Usual residence of chronic respiratory diseases such as bronchial asthma
Urban* 1.000 and COPD provides useful information on tobacco
Rural 0.705 (0.615-0.809) 0.559 (0.480-0.652)
Mixed 1.743 (1.192-2.547) 1.328 (0.876-2.013)
smoking especially with reference to different smoking
Gender forms and relationship with demographic variables. The
Female* 1.000 prevalence of smoking in 28.5% of men and 2.1% of
Male 1.124 (0.844-1.495) 1.359 (1.004-1.840) women reported in this study is generally similar to the
Age median prevalence of 30.6% reported in a cross sectional
15-24 years* 1.000
household survey from 26 states of India8. There was,
25-34 years 1.132 (0.618-2.072) 1.175 (0.639-2.159)
35-44 years 1.960 (1.099-3.495) 2.014 (1.125-3.607) however a wide range of the prevalence rate from the
45-54 years 3.433 (1.944-6.061) 3.399 (1.916-6.029) lowest of 13.9% in Punjab to the highest of 49.4% in
55-64 years 5.528 (3.128-9.770) 5.710 (3.211-10.156) Mizoram8.
65-74 years 9.154 (5.178-16.183) 9.030 (5.065-16.098) There are quite a few reports on the smoking habit in
>=75 years 10.201 (5.636-18.465) 10.435 (5.702-19.096)
India published in the past decade. In particular, the
Socio-economic
status habit has been studied amongst the school going youth
High * 1.000 of 13 to 15 years age as a part of the Global Youth
Medium 0.491 (0.385-0.627) 0.322 (0.240-0.430) Tobacco Survey (GYTS) sponsored by the Centre for
Low 0.270 (0.207-0.352) 0.548 (0.420-0.715) Disease Control (CDC), USA and the World Health
Any respiratory Organization (WHO)9-12 under the same programme,
symptom
No* 1.000 1.000
the smoking habit was also studied amongst adults
Yes 3.113 (2.677-3.621) 2.180 (1.850-2.568) working in the schools, i.e., the Global School Personnel
Survey (GSPS)14,15. There was a large variation in current
*: Reference category.
daily smoking from 14.4% in Rajasthan to over 50% in
We also analysed the presence of individual the North Eastern states14,15. The prevalence of ‘ever any
respiratroy symptoms in ever smokers, nonsmokers tobacco use' was much higher.
exposed to environmental tobacco smoke and the Bidi, the hand rolled form of tobacco, wrapped in the
individuals exposed to exhaust of solid fuel dried tendu leaf, was the most common smoking
combustion. In ever smokers, almost all respiratory product in this study especially in the rural population.
symptoms were two to three times as commonly seen as This is quite consistent with reports of the earlier
2006; Vol. 48 The Indian Journal of Chest Diseases & Allied Sciences 41

Table 7. Respiratory symptoms in relation to smoking status, and comparison with exposure to solid fuel combustion and ever exposure
to household environmental tobacco smoke (ETS)
Never Smoker Ever Smoker Exposed to Ever Exposed
Solid Fuel to ETS*
Combustion*
Wheezing 1610 (2.6%) 598 (5.2%) 280 (3.1%) 781 (2.8%)
Morning chest tightness/breathlessness 1431 (2.3%) 573 (5.0%) 225 (2.5%) 698 (2.5%)
Dyspnea on exertion 3145 (5.1%) 1101 (9.6%) 502 (5.6%) 1441 (5.1%)
Dyspnea without exertion 1159 (1.9%) 496 (4.3%) 202 (2.3%) 549 (1.9%)
Breathlessness at night 1221 (2.0%) 485 (4.2%) 190 (2.1%) 590 (2.1%)
Cough at night 1480 (2.4%) 869 (7.6%) 223 (2.5%) 729 (2.6%)
Cough in morning 1428 (2.3%) 915 (8.0%) 241 (2.7%) 677 (2.4%)
Phlegm in morning 1301 (2.1%) 851 (7.4%) 207 (2.3%) 613 (2.2%)
Breathlessness-always 427 (.7%) 189 (1.6%) 62 (.7%) 171 (.6%)
usually 1584 (2.6%) 625 (5.4%) 256 (2.9%) 726 (2.6%)
Tightness in chest with dust exposure 2309 (3.7%) 688 (6.0%) 245 (2.7%) 983 (3.5%)
Dyspnea with dust exposure 2489 (4.0%) 762 (6.6%) 279 (3.1%) 1088 (3.8%)
Ever asthma 1267 (2.0%) 437 (3.8%) 182 (2.0%) 637 (2.3%)
Attack of asthma 753 (1.2%) 245 (2.1%) 123 (1.4%) 401 (1.4%)
Inhaler use 1159 (1.9%) 400 (3.5%) 142 (1.6%) 513 (1.8%)
Any of the above 3945 (6.4%) 1602 (13.9%) 615 (6.9%) 1801 (6.4%)
*: Data only for never smokers.

studies16,17. Hookah smoking, the more traditional way in
which tobacco is kept in a earthen pot (chillum) along
with the burning coal and smoked through a water-
container with the help of a long pipe was present in
about 6% of rural and less than 1% of urban smokers.
Apparently, this traditional form of smoking is largely
extinct in the cities. Even in the villages, the hookah is
gradually giving place to bidi and/or cigarette smoking.
On an average the number of cigarettes or bidis smoked
daily was similar in both rural (15±17) and urban (12.4
±10.7) areas. Similarly, the mean age of starting smoking
was similar in both the populations.
Male sex, poverty and low education are the more
frequently reported factors of importance among
smokers. In the National Sample Survey in 1995-96
amongst subjects of over 10 years of age, the regular use
of both tobacco and alcohol increased significantly with
each diminishing income quintile18. In Mumbai, both
education and occupation were found to have
simultaneous and independent relationship with
tobacco use19. Similar observations are made in Western
literature, people with low income were reported to
more than twice as likely to smoke in the United
States20.
It is quite noteworthy that about 14 percent of
subjects reported the presence of one or the other
respiratory symptoms. About half this number among
nonsmokers exposed to environmental tobacco smoke
from the smoker parents, spouses or colleagues,
reported similar symptoms. Similarly, exposure to the
exhausts from combustion of solid fuels was responsible
for respiratory symptoms in about 7 percent of
symptoms. It can be indirectly concluded that the
magnitude of respiratory morbidity caused by exposure
to either ETS or solid fuel combustion in nonsmokers is
similar and that smokers are twice as likely to suffer
from respiratory symptoms. We have reported similar
findings on the subject in our earlier studies21.
Another important observations in this study was
made with reference to the ex-smokers. About 10
percent smokers among both the men and women had
quit smoking for about a year or more. This was more
so in the urban population, those belonging to the
higher socio-economic group and those who had
developed respiratory symptoms (and possibly other
tobacco related problems, which were not included in
the study). This may also partly reflect a trend of a
positive outcome of the vigorous anti-tobacco measures
under the tobacco control programmes adopted in the
last few years by India, a signatory to the Framework
Convention on Tobacco Control.
ACKNOWLEDGEMENTS
The study was supported by a financial grant from the Indian
Council of Medical Research, New Delhi. Authors also express
their gratitude to members of the Asthma Task Force of Indian
Council of Medical Research for their suggestions and help.
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