Dual Burden of Smoked and Smokeless Tobacco Use in India, 2009-2017: A Repeated Cross-Sectional Analysis Based on Global Adult Tobacco Survey

Nicotine Tob Res. 2020 Dec 12;22(12):2196-2202. doi: 10.1093/ntr/ntaa033.


Introduction: The dual use of smoked and smokeless tobacco (SLT) poses a serious challenge to tobacco control efforts. This article examines the trends and patterns of this usage in India during the period 2009-2010 and 2016-2017.

Methods: Data from two rounds of nationally representative cross-sectional Global Adult Tobacco Survey (GATS) conducted in 2009-2010 and 2016-2017 have been used. Dual use was assessed based on current smokers and SLT users in both rounds.

Results: Findings reveal that dual use in India has dropped from 5.3% during 2009-2010 to 3.4% during 2016-2017, a decline of nearly 10 million dual users. However, some states have added nearly 4.6 million new dual users during this period. While dual use continues to remain high in rural areas, there has been a manifold increase in urban areas. Findings revealed that intention to quit tobacco was lower among dual tobacco users as compared to single users with considerable difference between urban and rural areas.

Conclusion: Easy availability and affordability of SLT products compared to smoking products and restrictions on smoking in public places may have pushed current smokers and dual users to take to or intensify their SLT consumption. Measures relating to awareness, pricing, taxation, and enforcement of tobacco control laws should focus on all forms of tobacco, especially targeting high dual burden in rural and urban settings.

Implications: Dual form of tobacco users represent 12% of all tobacco users in the country. The study reveals that intention to quit tobacco among dual users is significantly lower than that among single tobacco product users. This requires improving public awareness about the morbidity and mortality that arises from the use of all forms of tobacco products. Efforts to restrict the availability of tobacco products should focus on licensing the sale of all tobacco products. Reduction in dual tobacco use will not only result in multiplied health benefits but also help in achieving the Non-Communicable Diseases targets under the United Nations Sustainable Development Goals.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Cross-Sectional Studies
  • Female
  • Global Health
  • Humans
  • India / epidemiology
  • Male
  • Middle Aged
  • Rural Population / statistics & numerical data*
  • Smoking / epidemiology*
  • Smoking / psychology
  • Surveys and Questionnaires
  • Time Factors
  • Tobacco Use / epidemiology*
  • Tobacco Use / psychology
  • Tobacco, Smokeless / statistics & numerical data*
  • Young Adult