The Progression of the Tobacco Epidemic in India on the National and Regional Levels, 1998-2016

Background: According to the smoking epidemic framework, societies undergo successive stages in which the prevalence of tobacco use first increases, and then declines. This pattern was has been extensively documented for developed countries, but evidence that it has occurred in low- and middle-income countries remains fragmented. We assessed the progression of the tobacco epidemic in India on the national and regional levels by gender, including trends in the consumption of smokeless tobacco, to provide a comprehensive overview of tobacco use in India and its states.Methods: We use information on current tobacco consumption among Indians aged 15-49 from three rounds of the National Family Health Survey (NFHS) (1998-99, 2005-06, 2015-16) to estimate the age-standardized smoking and smokeless tobacco prevalence across India and its states.Results: Age-standardized tobacco consumption prevalence in India increased between 1998-99 and 2005-06, and declined from 2005-06 to 2015-2016, simultaneously for men and women. There are substantial spatial differences in the progression of the tobacco epidemic in India. In the north-eastern states in particular, tobacco consumption prevalence remains higher than the national average, and is still increasing. Conclusions: Our results suggest that India and the majority of its states experienced a ‘compressed tobacco epidemic’ in which the prevalence of tobacco consumption increased and decreased simultaneously for women and men over a comparatively short period of time. Despite the overall progress in reducing tobacco use India has made, further lowering tobacco consumption remains a public health priority, as the prevalence of smoking and/or smokeless tobacco use remains high in a number of states. We therefore conclude that tobacco regulations should be expanded with the aim of reducing the overall health burden associated with tobacco consumption across India.