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Review Article

Indian J Med Res 126, October 2007, pp 289-299

Tobacco, education & health

P.C. Gupta & Cecily S. Ray

Healis - Sekhsaria Institute for Public Health, Navi Mumbai, India

Received June 5, 2007

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




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,

available studies in Sub-Saharan African countries do

not have consistent results on the relationship between
smoking and education. In Africa, cigarette smoking
tends to be more of an urban phenomenon, and other
forms of tobacco, such as home-made snuff are used
more by rural populations14.
With growing awareness of the health risks and
declines in smoking prevalence in many countries, these
declines are now being measured with reference to
educational levels and other socio-economic variables.
Analysis of four cross-sectional national surveys
conducted in the United States between 1971 and 2002
revealed that the higher prevalence of smoking among
persons with the lower levels of education (less than a
high school education or high school graduation only)
persisted over the period and the disparity had widened
despite declines in smoking in all groups15.
Comparison of national cross-sectional surveys
conducted in nine European countries between 1985
and 2000 (a period characterised by intense tobacco
control policies) on men and women aged 25-79 yr
found that overall, greater declines in smoking were
seen among persons with post-secondary education, but
country-wise analyses revealed that in Italy and the UK
those with elementary education level showed greater
declines than the more highly educated, which may be
due to specific tobacco control policies16.
In China, a cross-sectional survey representing the
entire country conducted in 1996 found that about 37.6
per cent overall smoking prevalence and about 9.4 per
cent of 45,995 current smokers had quit. Respondents
with a university education were more likely to have
made an attempt to quit. About 16 per cent of current
smokers said they intended to quit, but had not taken
any action, while 72 per cent of current smokers reported
not intending to give up smoking. A conclusion was
that smokers in China need to be mobilised to quit17.
Declines in smoking are occurring faster in
developed countries respect to developing countries.
In both it is observed that declines usually occur faster
in the more highly educated.
Evidence from India
Tobacco use is much more common among the less
educated and less privileged sections of the society:
Smoking has been widespread in India for many
decades. The National Family Health Survey-2
(NFHS-2) shows a gradient on two general types of





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.

tobacco use for educational level. An independent

analysis of the NFHS-II data showed that prevalence
of tobacco use decreases with increasing years of
education, as also shown by odds ratios (OR) of
tobacco use for different educational levels (Fig. 1 a
& b). The gradient is stronger for smoking than for
chewing and steeper for women than for men. The
inverse trends seen for smoking and chewing by
educational level were highly significant for men and
women. This survey comprised 334,553 individuals
(160,871 men and 154,726 women) 15 yr and older in
91,196 households19.
In the large house-to-house baseline survey
conducted on for a cohort study in Mumbai during
1992-9420 on adults belonging largely to the middle, lower
middle, and lower classes, a separate analysis of 81,837
respondents showed an educational gradient for all
tobacco use21. The odds ratios for any kind of tobacco
use among the illiterate compared to the college educated
were 7.38 for males and 20.25 for females after adjusting
for age and occupation. In this population smokeless
tobacco use was more common than smoking.
In this survey, bidi smoking and cigarette smoking
were about equally common. The different educational
gradients for cigarette smoking, bidi smoking and
smokeless tobacco use were calculated. With age
adjustment all the gradients showed an inverse
relationship of tobacco use with education. Cigarette
smoking, practiced almost exclusively by men, had the
educational gradient with the smallest incline. The
slightly more common bidi smoking, also practiced
almost exclusively by males, had the steepest
educational gradient, while that for smokeless tobacco
use practiced by men had a moderate incline. For

women, smokeless tobacco had a steep educational

gradient21 (Fig. 2).
Other studies of tobacco use prevalence in the
metropolitan cities of Delhi and Kolkata also found
inverse educational gradients for tobacco use, with the
highest tobacco use among the illiterates. In Delhi, men
with no education were 1.8 times more likely to smoke
than men with college education and women were 3.7
times more likely. Among adult smokers, about half of
the men (52.6%) and 4.9 per cent of women smokers
smoked cigarettes. Compared with cigarette smokers,
bidi and chutta smokers tended to be older, married,
less educated and to have lower incomes and lower body
mass indices and not have a family history of heart
disease22. In Kolkata just over one fourth of smokers
(26%) and just over one tenth (11.5%) of chewers were
college graduates and above. Filter cigarettes were the
most common products used (47.2%) in Kolkata,
followed by bidis (35.6%)23.
In a cross-sectional sample survey (Sentinel Survey)
of the ICMR and WHO on 35,288 persons aged 10 and
above in Karnataka and 29,931 in Uttar Pradesh, a
negative association between education and tobacco use
was observed overall and in most of the age groups24.
There was a markedly lower prevalence of tobacco use
in persons with college education compared to others.
This survey did not investigate further the reasons for
this phenomenon.
Interest in quitting appears related to higher levels of
education: In the Sentinel Survey on Tobacco Use 24,
interest in quitting was very low overall, especially in
Uttar Pradesh, where 3.5 per cent of men and 1.4 per
cent of women using tobacco had ever thought about
quitting, but less than half of those were currently







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).

interested and only 5 men and 1 women (<0.1%) could

quit. The situation in Karnataka was considerably
better. Here, 18.4 per cent of men and 9.3 per cent of
women using tobacco had ever considered tobacco
cessation, but only 4.0 per cent of men and 2.2 per
cent of women were able to actually quit the use of
tobacco. Awareness of disease risks was rather low,
except for cancer. It thus appears that the population
in general lacks motivation to avoid or quit tobacco
use, but it is notable that Karnataka has higher literacy
rates (F 44%; M 67%; 7 yr) than Uttar Pradesh
(F 25%; M 56%; 7 yr)25.
Proportions of past users in the baseline survey of
the Mumbai Cohort Study were low, ranging from 3.6
per cent for women users of smokeless tobacco to 12.9
per cent among men who had smoked cigarettes. In
between these rates, 4.3 per cent of men who used
smokeless tobacco and 5.4 per cent of men who smoked
bidis had quit. Quit rates among the more educated
group (high school and above) were more than twice
those among the less educated for both men and women
who were past users of smokeless tobacco and for men
who had smoked cigarettes20.

Youth who drop out of school or whose parents have a

low educational attainment take up tobacco use earlier
than others and/or have a higher prevalence of tobacco
use: A handful of available studies on youth indicate an
inverse relationship between education and tobacco use
in youth26,27.
Studies in rural children with low socio-economic
status (indicating low educational level of parents)
have found children starting to use tobacco by 10 years
in Gujarat, Karnataka and Tamil Nadu 28, or even
before age five, in Goa, where the most common
tobacco products used by children were for brushing
teeth (mishri and creamy snuff), as learnt in the
Fishing communities in Kerala have higher school
dropout rates and lower levels of literacy compared to
the rest of the State, and in these communities there is a
higher prevalence of tobacco use among both adults
and youth. A small survey of 146 youth aged 5-20 yr
found 29 per cent of them chewing pan-tobacco and 2
per cent smoking, whereas surveys in other parts of
Kerala had found less than 2 per cent of children below
16 yr using any form of tobacco30.


Child and adolescent workers tend to be influenced

by their seniors and employers in taking up smoking,
tobacco chewing, other substance abuse and sometimes
other risky behaviours31, 32. Youth workers aged 15-24
yr tend to have a high prevalence of tobacco use that
may reach sixty percent and above26.
A study of 1000 school boys in urban Gujarat found
that sons of mothers with university education did not
smoke, while 6.9 per cent of boys with illiterate mothers
and 4.4 per cent of boys with mothers having up to
secondary education smoked33. An unpublished survey
of 300 street children in Mumbai (all non-school going)
found they mostly began using tobacco by 8 yr of age26.
Surveys conducted in Delhi 34 found that generally
children in government schools took up tobacco use in
greater proportion than children in private schools (a
surrogate for higher educational attainment of parents).
A survey of school personnel in Bihar found that indeed
state schools were without policies prohibiting tobacco
use by students or personnel, but that over half of federal
schools (under the Union Government) had such
In an early study of 1278 boys in 10th standard in
Mumbai, tobacco use, mainly smoking, was found much
higher in private schools than in government schools36.
However more recent studies in Mumbai, both
published and unpublished, have found that a visibly
higher proportion of children in municipal schools use
tobacco and that gutka is the predominant form. In a
recent unpublished study of 30,000 municipal school
children in Mumbai, 50 per cent of them consumed 1-2
sachets of gutka every day37. In a very small Mumbai
study in different types of secondary schools, gutka was
found used by 10 per cent of boys38. In many school
surveys in urban areas, children using tobacco reported
initiating its use in the early to mid-teen years26.
Student youth taught about the dangers of tobacco use
in school are less likely to initiate tobacco use: Although
in some developed country scenarios (e.g., in Canada),
knowledge about the long-term health consequences of
smoking has been found to be only a weak predictor of
smoking initiation39, in India the opposite seems to be
more likely at present.
In India, the Global Youth Tobacco Survey
(2001-2005), conducted among students aged 13-15
yr40, showed that the prevalence of curricular teaching
about the hazards of tobacco use (half of the students


had been taught), or a discussion of reasons why people

their age smoke (one third had discussed this in class)
was strongly and negatively correlated (P<0.001) with
a current prevalence of tobacco use41.
For example, in Bihar, where only 2.7 per cent of
the students in grades 8-10 were taught about the
dangers, there were 13.9 per cent current cigarette
smokers and 46.7 per cent current users of other tobacco
products, while in Punjab, where 75.5 per cent were
taught about the dangers, there were 0.5 per cent current
cigarette smokers and 2.1 per cent current other tobacco
School policies on tobacco use and anti-tobacco
curricula that are part of a broad, health promotive and
participatory health education curriculum appropriate
for age have been effective in preventing tobacco use
and promoting activism against tobacco in India41.
Tobacco expenditure leads to a crowding out of
expenditures devoted to food and education and a
rise in health care: In an econometric analysis of
household expenditures from National Sample
Survey data42 on Indian households for the year 19992000, spending patterns on various groups of
commodities were analyzed by the household status
of tobacco consumption 43. It was found that an
increase in the outlay for tobacco led to a fall in the
budget share devoted to food, education, and
entertainment in rural India, while it led to a rise in
the shares devoted to health care, clothing, and fuels.
A similar increase in tobacco expenditure in urban
India led to a decrease in the budget shares for food,
education, fuel, and entertainment while leading to a
rise in the shares of health care and conveyance.
Higher expenditure on tobacco was also found to be
associated with higher expenditures on alcohol and
pan (betel quid). The effects of tobacco expenditure
on the consumption of other goods were found to
be in the same direction for both low income and
high income households. Further analysis of the
implications of reduced food expenditure on the
nutrition intake of households revealed that per capita
per diem intake of nutrients such as calories, protein
and fat are lower among high tobacco spending
households. The findings here support the idea that
expenditure on tobacco has crowding out effects, as
observed in other developing countries. The higher
expenditures on health care by families consuming
tobacco are likely to be related to diseases and
conditions caused by tobacco.



Most tobacco related diseases eventually require

hospitalisation. Yet, hospitalisation frequently results
in financial catastrophe for Indian families, as only 10
per cent have some form of insurance and most forms
are inadequate. A conservative estimate finds that onefourth of hospitalised Indians were not poor when they
entered the hospital but became so because of hospital
expenses, often after having borrowed money or having
sold off assets44.
Premature death caused by tobacco use in the
under-privileged section of the society often takes away
the major wage earner in the family. Thus plunges
families into further hardship, where the educational
needs of children are less likely to be met. Hence
tobacco use is an indirect risk factor for the destitution
of families.
The overall excess risk of death and the specific risks
of certain major diseases: In India, most adult deaths
involve vascular disease, tuberculosis, or other
respiratory disease. A large case-control study of adult
deaths in Tamil Nadu showed that vascular diseases are
the most predominant, followed by respiratory and
neoplastic diseases (cancers)45.
Overall mortality
In the Mumbai Cohort Study the age and education
adjusted relative risk (RR) of death for men who smoked
cigarettes was 1.37 (95% CI 1.23-1.53) and for men
who smoked bidis was 1.64 (95% CI 1.47-1.81), with a
significant dose-response relationship for number of
bidis or cigarettes smoked. For women tobacco users,
mainly smokeless tobacco users, the adjusted relative
risk was 1.25 (95% CI 1.15-1.35). It is notable here
that the relative risk of death for bidi smokers, mostly
less educated than cigarette smokers, is higher than that
for cigarette smokers46.
Association with diseases
Cardiovascular disease: In the Mumbai Cohort Study,
men who smoked had a relative risk (RR) of 1.54
(95%CI: 1.09-2.19) of dying of other cardiovascular
diseases, but only RR=1.17 (95%CI: 0.99-1.39) for
dying of ischaemic heart disease. In this study,
smokeless tobacco use posed a small significant
excess risk of death in women due to ischaemic heart
disease, but not for men and not other cardiovascular
diseases 46 .
A cross-sectional survey in a cluster of three villages
in rural Rajasthan, among 3148 residents aged over

20 yr (1982 men and 1166 women) found a total

prevalence of coronary heart disease of 3.5 per cent
(111 cases), with 3.4 per cent (68 cases) in men and 3.7
per cent (43 cases) in women. An overall decrease in
the prevalence of coronary heart disease with increasing
educational status was apparent in both sexes, but the
trend was significant only in women ([X.sup.2] = 7.25;
P = 0.007). The prevalence of coronary heart disease
(diagnosed by electrocardiography) was significantly
higher among uneducated and less educated people, and
showed an inverse relation with education in both sexes.
Among uneducated and less educated people there was
a higher prevalence of the coronary risk factors smoking
and hypertension. Logistic regression analysis
with adjustment for age showed that educational
level had an inverse relation with prevalence of
electrocardiographically diagnosed coronary heart
disease (ORs: men 0.82, women 0.53), hypertension
(ORs: men 0.88, women 0.56) (P< 0.011 for chi square
for men; P< 0.001 for women), and smoking (OR for
men 0.73, for women 0.65) (P < 0.001 for chi square
for men and women) but not with hypercholesterolaemia
and obesity47.
In the case-control study in Tamil Nadu, the risk
ratio for ever to never smokers for stroke was 1.6
(95% CI: 13-19). Twenty per cent of stroke cases were
considered smoking associated45.
Chronic obstructive pulmonary disease: In the Mumbai
Cohort Study, male smokers had a relative risk of 2.1
(1.53.1) of dying of COPD, but for women smokers
the relative risk did not reach significance46.
In an ongoing multi-centric cross-sectional survey
of 35,295 adults aged 35 yr and above in both urban
and rural areas in or around Bangalore, Chandigarh,
Delhi and Kanpur, COPD was diagnosed in 4.1 per
cent of individuals. Prevalence among bidi and
cigarette smokers was 8.2 and 5.9 per cent,
respectively. Significantly elevated odds ratios for
COPD were seen for cigarette smokers 1.95 (95% CI:
1.6-2.4), bidi smokers 2.7 (95% CI: 2.3-3.1) and
hookah smokers 2.9 (2.0-4.1) compared to nonsmokers
(by multivariate logistic regression). Odds ratios for
COPD were higher for lower socio-economic status,
urban residence and age. Environmental tobacco
smoke exposure among nonsmokers had an OR of 1.4
(95% CI: 1.2-1.6)48.
A cross-sectional study in Delhi of 4141 residents
18 yr and above (56.6% males) interviewing them about
chronic respiratory symptoms (chronic cough, chronic


phlegm, breathlessness and wheeze) and smoking

history followed by a clinical examination and
spirometry found 39.1 per cent smokers and 6.7 per
cent ex-smokers among men and 2.6 per cent among
women. Analysis was restricted to men due to low
smoking prevalence among women. The prevalence of
bidi smoking (59.7%) versus cigarette smoking (29.4%)
showed a strong educational gradient over 5 educational
groups, with bidi smoking more common among the
less educated subjects and illiterates (chi square =
364.15, P<0.00001). The proportion of symptomatic
patients increased with pack-years of smoking and was
consistently higher for bidi smokers in each of the four
groups of smoking intensity, varying from 13.8 per cent
of bidi smokers and 8.3 per cent of cigarette smokers in
Group 1 (< 2.5 pack-years) to 67.4 per cent of bidi
smokers and 46.8 per cent of cigarette smokers in Group
4 (> 13.5 pack years). Bidi smokers also had
significantly lower lung function values compared to
cigarette smokers. It was concluded that chronic
obstructive respiratory disease was considerably more
common in the less educated groups, especially the
Tuberculosis: In the Mumbai Cohort Study, men who
smoked during the study period had a relative risk of
2.30 (95% CI: 1.68-3.15) for death due to TB46.
In a case-control study in Chandigarh with 200
patients of tuberculosis (TB), and two sex and age
matched control groups, comprising patients with other
respiratory illnesses and apparently healthy volunteers,
smoking was significantly associated with the risk of
active pulmonary TB. Adjusted odds ratios for smokers
versus non-smokers were 5.4 (95%CI: 3.1-9.6)
comparing cases with the respiratory illness group, and
4.4 (95%CI: 2.6-7.7) comparing cases with the healthy
group. Exposure to patients with TB was also of course
an important risk factor both when comparing with
the respiratory illness group (OR=2.7; 95% CI: 0.987.3) and with the healthy group (OR=5.4; 95% CI:
1.5-19.6). In this study, the proportion of cigarette
smoking in all the groups was slightly higher than bidi
A risk ratio of 45 (95% CI: 40-50) for ever
smokers dying of TB was found in a population-based
case control study conducted in Tamil Nadu on the
smoking habits of 27,000 urban and 16,000 rural men
who had died from medical causes. As many as 1127 or
61 per cent of the 1840 tuberculosis deaths in the study
population were associated with smoking45.


Cancer: In the Mumbai Cohort Study, male smokers

had a RR of 2.6 (95% CI: 1.8-3.8) for dying of any
cancer, but for dying of oral and pharyngeal cancers
the RR was 19.7 (95% CI: 2.7-146.2) and that for
respiratory cancers was RR=4.1 (95% CI: 1.5-10.9). The
two relative risks for dying of cancer for smokeless
tobacco use for men [RR=1.40 (0.95-2.06)] and women
[RR=1.6 (95% CI: 1.2-2.1)] were quite comparable46.
In a hospital based case-control study with 142 male
anterior tongue cancer patients and 635 controls, the
illiterate group showed an almost 2-fold significant
excess risk (OR=1.8; 95% CI: 1.2-2.7) for anterior
tongue cancer compared to the literate group, in a
multiple logistic regression. Tobacco chewing was the
other predominant risk factor with an odds ratio of 1.7
(95% CI: 1.2-2.6)51.
In a hospital-based case-control study of men with
oropharyngeal (678 cases), hypo-pharyngeal (593 cases)
and laryngeal cancer (427 cases), with 635 controls,
illiterate men had 50-60 per cent excess risk for
pharyngeal cancers compared to literate men, while
literacy did not appear to play a role for laryngeal cancer.
Bidi smoking was the predominant risk factor for these
three cancers, with odds ratios of 4.7 (95% CI: 3.6-6.3)
for oropharyngeal cancer, 2.8 (95% CI: 2.1-3.7) for
hypopharyngeal cancer and 2.1 (95% CI: 1.6-2.8) for
laryngeal cancer52.
Risk factors for lung cancer were studied in a casecontrol study in Chandigarh with 265 patients (235 men,
30 women) and 525 hospital controls (435 men; 90
women) matched on age and sex. Effects of smoking,
indoor and outdoor air pollution and occupational
exposures were assessed. Smoking cigarettes (OR=5.6;
95% CI: 3.15-10.1) or bidis (OR=5.76; 95% CI: 3.429.70) was the main risk factor for causation of lung
cancer in men. In women the association with smoking
was not so strong, suggesting the operation of other
risk factors. Education (versus no schooling) showed a
protective effect for lung cancer. For post-graduates the
odds ratio of developing lung cancer was 0.69 (95%
CI: 0.27-1.76), compared to the no-schooling group and
adjusted for tobacco consumption. This effect of
education was not attributable to smoking itself as it
persisted even after adjustment for smoking 53.
Occupationally related diseases: Blue collar (hence less
educated) workers who smoke are more vulnerable to
occupational diseases, e.g., pneumoconiosis, byssinosis,
occupationally related asthma, chronic bronchitis and



emphysema, cancers of the lung, urinary bladder, liver,

skin, or stomach and myeloid leukaemia. Some of these
risks are additive and others multiplicative.
Occupational health services need to be combined with
smoking cessation services to protect workers from
occupationally and smoking related diseases54.
Involuntary smoking related diseases and health
outcomes: India has generated evidence on risks due to
involuntary tobacco smoke being a cause of lung
cancer 55 , worsening of asthma in children 56 ,
adolescents57 and women58, respiratory infections in
young children59, and low birth weight60.
Adverse reproductive outcomes of smokeless tobacco
use: In a cohort study of 1217 pregnant women availing
of municipal health services in Mumbai for antenatal
care, 17 per cent of the women were using smokeless
tobacco. Pregnant women who used smokeless tobacco
less than five times a day had a 50 per cent higher risk
after adjustment for confounding variables [risk ratio
=1.5 (95% CI: 0.9-2.4)] of having a low birth weight
baby while in those using it five or more times daily,
the risk was over 100 per cent higher than in non-users
[risk ratio = 2.1 (95% CI:1.1-4.0)] 5. In a further
analysis of data from the same study , smokeless
tobacco users had an adjusted risk ratio for stillbirth
of 2.6 (95% CI: 1.4-4.8)61.
Tobacco use by the least educated is in large
measure practiced in ignorance of the health
consequences, with belief in medicinal properties of
tobacco (e.g., for cleaning teeth, for relieving toothache,
for preventing constipation and relieving gastric
complaints like gas and stomach acidity) and a desire
for a low cost source of pleasure and satisfaction. If the
film hero smokes, a youth may want to emulate him.
The illiterate cannot read statutory health warnings.
Among the more educated and urban population,
tobacco use seems to be more in response to peer
pressures and advertising, while some knowledge of
possible health consequences is laid aside as irrelevant
for the present62,63.
Reasons for tobacco use are fairly clear, but reasons
for non-use, also important, have not been studied. It is
not useful to assume that all non-users are more aware
of or motivated not to use tobacco by knowledge of the
health hazards, since tobacco use initiation can take
place at any age. Why there is a markedly lower
prevalence of tobacco use in persons with college

education compared to others is also not known.

Researchers have suggested that this phenomenon needs
to be studied24. Indeed, such information would be
useful for counselling non-tobacco using patients and
for designing effective preventive interventions.
It has been argued that increasing the educational
level of the population will contribute to their better
health and it is seen that with increasing educational
levels, tobacco use decreases. Hence better health would
It has been hypothesized and found that a low level
of life satisfaction is a risk factor for smoking. For
example, among 2201 Chinese rural migrants aged 1830 yr who reported more dissatisfaction with their lives
or their jobs in the city, smoking was more prevalent
among men with less education, but more prevalent
among women with more education65. Low levels of
life satisfaction correlating with smoking could also
conceivably be associated with less education, but life
dissatisfaction and higher smoking prevalence has also
been found in a subgroup of college students66.
Regardless of the possible reasons for higher
prevalence of tobacco use among the less educated,
community intervention studies in India have proven that
educational interventions on the adverse effects of tobacco
combined with personalized support for quitting this
addiction receive a positive response and are successful
in getting educationally deprived users to quit67-69.
The fact that a large part of the work force of bidi
rollers are illiterate or educated only up to the primary
level contributes to perpetuating the production of the
most popular tobacco product in India70.
Tobacco use and its consequences are clearly an
impediment to the development of a healthy and
prosperous society. If education were more widespread
and the health care system addressed the problem of
tobacco use - including prevention and cessation - the
population would enjoy both more economic
opportunities and better health.
Tobacco, education, and health in a human
population are inter-related in ways that makes
sufferings and deaths caused by tobacco use even
more tragic than normally realized as they occur most
often among least educated and under-privileged
sections of the society.



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