|Ahead of print
Socio-demographic correlates of quit attempts and successful quitting among smokers in India: Analysis of Global Adult Tobacco Survey 2016-17
Jaya Prasad Tripathy
Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra, India
|Date of Submission||10-Mar-2019|
|Date of Decision||24-Oct-2019|
|Date of Acceptance||28-Oct-2019|
Jaya Prasad Tripathy,
Department of Community Medicine, All India Institute of Medical Sciences, Nagpur, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: MPOWER is a policy package of six components intended to assist in the country-level implementation of effective tobacco control interventions. One of the six components of MPOWER strategy is to offer help to quit tobacco use. Majority of the smokers want to quit, but quitting is difficult due to the addictiveness of nicotine. They make multiple quitting attempts with little success. There is a need to know what proportion of smokers make a quit attempt, and among those who make an attempt, how many become successful quitters and their sociodemographic correlates.
Methods: Secondary analysis of data from the Global Adult Tobacco Survey (GATS-2) 2016–17, India was done. This nationally representative survey was conducted among persons aged 15 years or older. Weighted estimates were calculated after adjusting for clustering and stratification.
Results: A total of 35.5% adults who smoked tobacco during the past 12 months have made a quit attempt in the last 12 months. Around 14.2% of ever daily smokers currently do not smoke (which indicate successful quit rate). The study demonstrated strong associations of sociodemographic characteristics such as age group, educational attainment, caste, religion, geographic region, wealth quintiles, and visit to health care provider with the attempt to quit tobacco and successful quitting. The majority of quit attempts were made without any assistance (71.1%).
Conclusion: The study provides robust national evidence on attempts to quit tobacco, the success rates of those attempts, and their sociodemographic correlates. The study highlights the need to provide more cessation support to young, less educated people in the northern part of India.
Keywords: Global Adult Tobacco Survey, quit rate, tobacco cessation
Key Message: Very few smoking quit attempts were successful due to lack of professional support. More cessation support is needed at a primary care level to improve success rates.
|How to cite this URL:|
Tripathy JP. Socio-demographic correlates of quit attempts and successful quitting among smokers in India: Analysis of Global Adult Tobacco Survey 2016-17. Indian J Cancer [Epub ahead of print] [cited 2021 Jan 19]. Available from: https://www.indianjcancer.com/preprintarticle.asp?id=297016
| » Introduction|| |
Tobacco use is one of the most important preventable causes of premature death in the world claiming 7.1 million lives in 2016. Globally, 942 million men and 175 million women aged 15 or older are current smokers.
To address this global challenge, the first international public health treaty namely the World Health Organization Framework Convention on Tobacco Control (WHO FCTC) came into force in 2005 which has been ratified by 181 countries. It is a guidance document for the countries to adopt and implement tobacco control measures. To assist in country-level implementation of the WHO FCTC, WHO also introduced a package of six technical measures termed as the MPOWER strategy. One of the key components of this strategy is to offer help to quit tobacco use.
Majority of the smokers want to quit, however, quitting is difficult for most smokers primarily due to the addictiveness of nicotine in tobacco.,, They make multiple quit attempts during their lifetime with little success. It is reported that only about 3–5% of unassisted quit attempts are successful.
India is home to nearly 100 million smokers. Nearly 1 million deaths are attributed to smoking each year. To prevent initiation of tobacco and help existing tobacco users quit tobacco, the Government of India initiated the National Tobacco Control Programme (NTCP) in 2007–08 for the implementation of various tobacco control initiatives at the national, state, and district levels. A key component of this program is to provide tobacco cessation services at the primary health care level. Under the tobacco-free initiative, the Government of India in collaboration with the WHO established 21 tobacco cessation clinics during 2001–2009 to provide tobacco cessation services. However, the coverage, uptake, and effectiveness of these cessation services are yet to be ascertained.
The Global Adult Tobacco Survey (GATS-2) 2016–17, the second nationally representative survey of key tobacco indicators in India, reported that in the last 12 months, 36% of current tobacco smokers made attempts to quit. There is a need to know who among the smokers made a quit attempt, and among those who made an attempt, how many became successful quitters and their socio-demographic correlates.
This needs to be further explored to better understand and implement effective tobacco cessation services within the country. The recent GATS dataset allows us to explore this in the context of newer tobacco control initiatives in the country in the last decade.
Thus, the current study aims to explore the sociodemographic characteristics and cessation services used by adults i) who attempted to quit smoking, and ii) who were successful in quitting.
| » Methods|| |
This is a cross-sectional study analyzing secondary data from the GATS-2 2016–17 which is already collected and available in public domain.
GATS is a nationally representative survey conducted among persons aged 15 years or older on key tobacco indicators. The second round of the survey was conducted in 2016–17 in India, the first round being implemented in 2009–10. It is a household-based survey designed to produce national and sub-national estimates on tobacco use, exposure to second-hand smoke, quit attempts among adults, and to measure the impact of tobacco control and other preventive initiatives. GATS India was conducted in all 30 states and 2 union territories covering about 99.9% of the total population. A multistage, geographically clustered sample design was used to draw a representative sample. In urban areas, a three-stage sampling was adopted, whereas in the rural areas, a two-stage sampling was followed. One individual was randomly chosen from each selected household to participate in the survey. In each selected household, electronic handheld device was used for household data collection. The survey interviewed 74,037 respondents (33,772 men and 40,265 women) aged 15 years and above with an overall response rate of 92.9%.
The exposure variables are age, sex, place of residence (rural/urban), education, occupation, wealth quintile, and use of tobacco cessation aids. The variable called “wealth quintile” was created using a summative score of inverse weighted proportions of possession of the following assets: electricity; flush toilet; car; moped/scooter/motorcycle; television; refrigerator; washing machine; air conditioner; electric fan; internet connection; computer/laptop; fixed telephone; cell phone; and radio. The summative score was then divided into quintiles to obtain wealth quintiles (lowest, lower, middle, higher, and highest), which was used as a proxy for wealth or socioeconomic status.
The outcome variables are smoking quit attempt in the past 12 months and successful quit attempt.
Smoking quit attempt in the past 12 months is defined as the percentage of adults who smoked tobacco during the past 12 months who tried to quit during the past 12 months.
Numerator: The number of current tobacco smokers who tried to quit during the past 12 months and former tobacco smokers who have been abstinent for less than 12 months.
Denominator: The total number of current tobacco smokers and former tobacco smokers who have been abstinent for less than 12 months.
Successful quit attempt is defined as the percentage of ever daily tobacco smokers who currently do not smoke tobacco.
Numerator: The number of ever daily tobacco smokers who currently do not smoke tobacco.
Denominator: The number of ever daily tobacco smokers.
Ever daily smokers include those who are current daily tobacco smokers or current occasional tobacco smokers, but former daily.
The survey data were imported into STATA Version 12 for analysis. Chi-square test was done to study the association between the independent and the dependent variables. Logistic regression models were applied to measure the strength of association and presented as adjusted odds ratio (OR) with 95% confidence interval (95% CI). A P value cut-off of 0.2 in the unadjusted model was set as the criteria to include a variable in the adjusted model. We tested for multicollinearity between the covariates using variance inflation factor values. Sampling weights were applied, and weighted estimates were calculated to account for the complex study design. Clustering and stratification were also accounted for by using svyset command in STATA. The following variables were used to apply weights and adjust for clustering and stratification: gatscluster, gatsstrata, and gatsweight.
The source of data for the study was a national survey conducted by the Government of India and the dataset is available in public domain. The Ethics Advisory Group of International Union against Tuberculosis and Lung Disease, Paris, France determined that ethics review was not required for this study.
| » Results|| |
Among 9748 current and former tobacco smokers (abstinent for <12 months), 3461 (35.5%) made a quit attempt during the past 12 months [Figure 1].
|Figure 1: Tobacco use and quit attempts in the past 12 months in Global Adult Tobacco Survey 2016–17, India|
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Among 9549 ever daily smokers (7647 current daily smokers and 1902 former daily smokers), 1353 (14.2%) are ever daily smokers who currently do not smoke which is also known as quit ratio [Figure 2].
|Figure 2: Tobacco use and successful quitting in Global Adult Tobacco Survey 2016–17, India|
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Among 9748 respondents who were assessed for any quit attempt in the last 12 months, regression model was applied to 9741 due to observations with missing data. Respondents who were Christians (OR: 0.6, 95% CI: 0.4–0.9), with no formal education (OR: 0.8, 95% CI: 0.6–0.9), and with no knowledge about the harms of tobacco (OR: 0.8, 95% CI: 0.6–1.0) were less likely to make a quit attempt. Those residing in the north (OR: 0.7, 95% CI: 0.6–0.9), the east (OR: 0.7, 95% CI: 0.5–0.9), and the west (OR: 0.4, 95% CI: 0.3–0.5) part of India also had lower odds of attempting a quit compared to south India. Those living in urban areas (OR = 1.2, 95% CI: 1.0–1.5), belonging to the other backward class (OR = 1.3, 95% CI: 1.0–1.5), and those who visited a health care provider in the past 12 months (OR = 1.8, 95% CI: 1.5–2.0) were more likely to make a quit attempt [Table 1].
|Table 1: Sociodemographic characteristics associated with the attempt to quit smoking in the past 12 months among smokers in Global Adult Tobacco Survey 2 India (2016-17)|
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Among 9549 respondents who were assessed for the success of quit attempt, regression model was applied to 9541 due to observations with missing data. Respondents who were aged 45–59 years (OR: 1.8, 95% CI: 1.2–2.7) and ≥60 years (OR: 3.6, 95% CI: 2.4–5.3), belonging to the other backward class (OR: 1.4, 95% CI: 1.1–1.7), educated till secondary (OR: 1.5, 95% CI: 1.1–2.0) or higher secondary (OR: 1.6, 95% CI: 1.1–2.4), and in the poorer wealth quintiles (OR: 1.5, 95% CI: 1.1–2.1) were more likely to make a successful quit attempt. Those residing in the northeastern part of India had a higher odds of a successful quit (OR: 1.4, 95% CI: 1.1–1.8), whereas those in north India were less likely to make a successful quit attempt (OR: 0.4, 95% CI: 0.3–0.6) [Table 2].
|Table 2: Sociodemographic characteristics associated with successful quit attempt among ever daily smokers in Global Adult Tobacco Survey 2 India (2016-17)|
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The majority of quit attempts were without any assistance (2461, 71.1%) followed by counseling (288, 8.3%), and switching to smokeless tobacco (131, 3.8%). Nearly 5.4% (185) of those who made a quit attempt used nicotine replacement therapy or any other prescription medications [Table 3].
|Table 3: Cessation aid used to quit smoking among current and former tobacco smokers who made a quit attempt in the last 12 months, GATS India 2016-17|
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| » Discussion|| |
The key findings of the study are: 1) One out of three adults who smoked tobacco during the past 12 months have made a quit attempt in the last 12 months, 2) one out of seven ever daily smokers currently do not smoke (which indicate successful quit rate), 3) the study demonstrated strong associations of sociodemographic characteristics such as age group, educational attainment, caste, religion, geographic region, wealth quintiles, and visit to a health care provider with the attempt to quit tobacco and successful quitting, and 4) a large majority of quit attempts are done without any assistance.
Only one out of three smokers made any attempt to quit. We need to understand the reasons why the remaining two did not attempt through a systematic qualitative enquiry. Although the success rate of quit attempts is not satisfactory, it is better than the quit rate of 5% shown in the previous literature. This is an encouraging sign and reflects the overall progress India has made in tobacco control in the last decade. But certainly, it is not sufficient and more needs to be done in this regard. One possible reason for failure to sustain after quitting is the fact that most quitters attempt without any professional help or assistance. The previous GATS analysis also showed poor uptake of cessation interventions. Thus, we need to improve the coverage and uptake of cessation aids. More operational research is required to study the role of cessation aids in successful quit attempts versus attempts made without any assistance for effective delivery of cessation interventions.
Those lacking formal education were found to be less likely to make a quit attempt and have less chances of a successful quit attempt as well. This was consistent with the analysis of the previous GATS dataset in India, Bangladesh, and Poland, thus highlighting the role of education in quitting behavior.,,
In contrast to the findings from previous research, the present study did not find any association between knowledge about the harms of tobacco and successful quitting, although it was associated with quit attempt.,, This clearly indicates that although knowledge about tobacco hazards leads to an intention to quit further leading to a quit attempt, just knowing is not enough to quit. Successful quitting requires more systematic planning and professional help.
There are significant geographic differences in quit behavior, especially among those residing in north India, where the likelihood of a quit attempt and success of quitting are less. These differences could be due to varying burden and pattern of tobacco smoking, sociocultural context, and cessation support available.
Attempt to quit was similar across all age groups, whereas elderly (≥45 years) age group was significantly associated with successful quitting which is also corroborated by previous assessments.,, We speculate that attempts made by elderly are well thought of and mostly in response to some critical triggering events such as poor health condition mandating tobacco cessation, whereas those by the young people are not well planned and impulsive. This probably explains the poor success rate of quit attempts among the younger age groups. Moreover, older smokers are more likely to show manifestation of smoking-attributable illness, which also may strengthen their intention to quit.
Gender was not associated with making quit attempt, which is in-line with some previous studies., But, there is a conflicting result of gender for predicting successful quitting. Some studies found that male smokers were more likely to be successful quitters, while other studies have found no such association between gender and successful quitting, similar to the findings of the present study.,,,, Further, few studies have also shown that female smokers were more likely to be successful quitters than male smokers.,
Respondents in the lowest two quintiles had a higher chance of successful quitting, which contradicts the findings from previous similar studies.[12-14,23] The exact reasons for this are unknown which requires in-depth qualitative exploration.
Strengths and limitations
The major strength of this study lies with the fact that it analyzed a nationally representative survey dataset on tobacco use and quit attempts in India. The survey employed a robust standardized GATS methodology and a large sample size, thus lending generalizability to the study results. Standard GATS definitions were used to measure the outcome variables. Analysis was carried out taking into account the complex sample design by applying weights and after adjusting for clustering and stratification.
There were some limitations in this study. First, we could only explore the sociodemographic correlates. Variables such as duration and intensity of tobacco use, and the level of addiction were not available for all ever daily users. Second, the study relied on self-reported responses to questions on issues such as tobacco use, tobacco quit attempts, and utilization of cessation services which might involve social desirability bias as a result of the perceived stigma. Third, many of the responses were not validated by more objective means such as measurement of cotinine levels in those who said they had quit. This could be an area of future research.
The study results have important policy implications. Only one-third of smokers made a quit attempt and very few of them were successful which means that more cessation support is required to improve success rates. Going forward, cessation services have to reach the primary care level in order to make a wider impact. The evaluation of tobacco cessation clinics in India showed that it is possible to establish effective tobacco cessation services in diverse health settings with the optimal use of existing infrastructure and minimal support. There is a need to build awareness regarding the availability and benefits of tobacco cessation services. Health care givers at all levels of the health care delivery system must be trained in tobacco dependence treatment including behavioral counseling and pharmacotherapy. Varghese et al. found that physicians, in general, lacked the knowledge of tobacco cessation protocols and were unable to handle the needs of their patients for tobacco cessation. The coverage of cessation services could also be improved by opportunistic screening of individuals for tobacco use at various points of health care contact and linking them to appropriate services.
The association of knowledge about the harms of tobacco and formal education in quitting smoking stresses on the need for a continuous, audience-driven, message-focused information, education, and communication (IEC) strategy under the NTCP. Geographic differences reported in this study imply that the NTCP should focus more on the north Indian states in terms of providing more cessation services and support. Younger adults were less likely to quit successfully, thereby requiring more cessation support and tailored cessation interventions for this age group.
| » Conclusion|| |
This study provides robust national evidence on the sociodemographic correlates of quit attempts and successful quitting in India. The study highlights the need to provide more cessation support to the younger, less educated people in the northern part of India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| » References|| |
U.S. Department of Health and Human Services. How Tobacco Smoke Causes Disease: The Biology and Behavioural Basis for Smoking-Attributable Disease: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2010. Available from: https://www.ncbi.nlm.nih.gov/books/NBK53017/
[Last accessed on 2020 Sep 02].
Vangeli E, Stapleton J, Smit ES, Borland R, West R. Predictors of attempts to stop smoking and their success in adult general population samples: A systematic review. Addiction 2011;106:2110-21.
Benowitz NL. Nicotine Addiction. N
Engl J Med 2010;362:2295-303.
Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction 2004;99:29-38.
Reitsma MB, Fullman N, Ng M, Salama JS, Abajobir A, Abate KH, et al
. Smoking prevalence and attributable disease burden in 195 countries and territories, 1990-2015: A systematic analysis from the Global Burden of Disease Study 2015. Lancet 2017;389:1885-906.
Kaur J, Jain DC. Tobacco control policies in India: Implementation and challenges. Indian J Public Health 2011;55:220-7.
] [Full text]
Srivastava S, Malhotra S, Harries AD, Lal P, Arora M. Correlates of tobacco quit attempts and cessation in the adult population of India: Secondary analysis of the Global Adult Tobacco Survey, 2009-10. BMC Public Health 2013;13:263.
Hakim S, Chowdhury MA, Uddin MJ. Correlates of unsuccessful smoking cessation among adults in Bangladesh. Prev Med Rep 2017;8:122-8.
Kaleta D, Korytkowski P, Makowiec-Dąbrowska T, Usidame B, Bąk-Romaniszyn L, Fronczak A. Predictors of long-term smoking cessation: Results from the global adult tobacco survey in Poland (2009-2010). BMC Public Health 2012;12:1020.
Ayo-Yusuf OA, Szymanski B. Factors associated with smoking cessation in South Africa. S Afr Med J 2010;100:175-9.
Tejada CA, Ewerling F, Santos AM dos, Bertoldi AD, Menezes AM. Factors associated with smoking cessation in Brazil. Cad Saude Publica 2013;29:1555-64.
Hyland A, Li Q, Bauer JE, Giovino GA, Steger C, Cummings KM. Predictors of cessation in a cohort of current and former smokers followed over 13 years. Nicotine Tob Res 2004;6(Suppl 3):S363-9.
Hymowitz N, Cummings KM, Hyland A, Lynn WR, Pechacek TF, Hartwell TD. Predictors of smoking cessation in a cohort of adult smokers followed for five years. Tob Control 1997;6(Suppl 2):S57-62.
Rose JS, Chassin L, Presson CC, Sherman SJ. Prospective predictors of quit attempts and smoking cessation in young adults. Health Psychol 1996;15:261-8.
Derby CA, Lasater TM, Vass K, Gonzalez S, Carleton RA. Characteristics of smokers who attempt to quit and of those who recently succeeded. Am J Prev Med 10:327-34.
Chen PH, White HR, Pandina RJ. Predictors of smoking cessation from adolescence into young adulthood. Addict Behav 2001;26:517-29.
Kim YJ. Predictors for successful smoking cessation in Korean adults. Asian Nurs Res (Korean Soc Nurs Sci) 2014;8:1-7.
Marti J. Successful smoking cessation and duration of abstinence—An analysis of socioeconomic determinants. Int J Environ Res Public Health 2010;7:2789-99.
Varghese C, Kaur J, Desai NG, Murthy P, Malhotra S, Subbakrishna DK, et al
. Initiating tobacco cessation services in India: Challenges and opportunities. WHO South-East Asia J Public Heal 2012;1:159-68.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]