|Year : 2017 | Volume
| Issue : 1 | Page : 26-30
'Loose' cigarettes association with intensity of smoking: A secondary data analysis from Global Adult Tobacco Survey, India, 2009-10
Mitasha Singh1, Vishal Dogra2, Ravinder Kumar3, Ajay M V Kumar4
1 Hamdard Institute of Medical Sciences and Research, New Delhi, India
2 School of Business, Mohali Campus, Punjab, India
3 Medical Consultant, Department of Health and Family Welfare, Shimla, Himachal Pradesh, India
4 Senior Consultant, International Union Against Tuberculosis and Lung Disease, South-East Asia Regional Office, New Delhi, India
|Date of Web Publication||20-Mar-2017|
Senior Resident, Department of Community Medicine, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard University, New Delhi - 110 062
Source of Support: None, Conflict of Interest: None
Context: Raising tax on tobacco products is one of the key tobacco control strategies. Globally, it has led to decrease in overall cigarette consumption but on the other hand contributed to increased sale and purchase of loose cigarettes. These loose cigarettes have many important public health implications. Aim: To assess the association between practice of buying loose cigarettes and intensity of smoking. Materials and Methods: A secondary analysis of Global Adult Tobacco Survey, India 2009–2010 data was performed in May 2014, on adult population age 15 years and above. The key outcome variable was “intensity of smoking” defined as average number of cigarettes smoked per day, whereas the key exposure variable was “practice of purchasing loose cigarettes.” Descriptive statistical analysis was performed using EpiData software (version 220.127.116.11) and STATA version 12.1. Results: Nearly, 57% of current cigarette smokers (approximately 3.46 million) bought loose cigarettes. The proportion of buying loose cigarettes decreased with increasing level of education and wealth index as well as least among government employees. The intensity of smoking was 70% less among loose cigarette buyers than nonbuyers (odds ratio [OR]: 0.29, 95% confidence interval [CI]: 0.24–0.34). It was found to be significantly lower in rural areas (OR: 0.81, 95% CI: 0.68–0.97) and among homemakers and those who had formal schooling. Conclusion: This study showed that loose cigarette buying is associated with decreased in smoking intensity. This may be due to increased taxes leading to increased buying of single cigarettes. These findings, therefore, highlight a need for a comprehensive policy and further studies on loose cigarette selling.
Keywords: Global Adult Tobacco Survey, loose cigarettes, raising taxes, smoking
|How to cite this article:|
Singh M, Dogra V, Kumar R, Kumar AM. 'Loose' cigarettes association with intensity of smoking: A secondary data analysis from Global Adult Tobacco Survey, India, 2009-10. J Sci Soc 2017;44:26-30
|How to cite this URL:|
Singh M, Dogra V, Kumar R, Kumar AM. 'Loose' cigarettes association with intensity of smoking: A secondary data analysis from Global Adult Tobacco Survey, India, 2009-10. J Sci Soc [serial online] 2017 [cited 2017 Aug 23];44:26-30. Available from: http://www.jscisociety.com/text.asp?2017/44/1/26/202540
| Introduction|| |
Globally, tobacco is used in many different forms, but manufactured cigarettes are most commonly used accounting for 96% of total worldwide sales. Globalization and rapid growth in tobacco industry have made cigarettes availability much easier. There has been an increase in cigarette consumption in low- and middle-income countries. The estimated number of cigarettes consumed was nearly 5.9 trillion in 2009, representing a 13% increase compared to the past decade (1999–2009).
India is home to a large population of smokers (~111 million), and about 46 million of them smoke cigarettes. Cigarettes have been sold in tins, cartons, packs, “kiddie” packs and as loose sticks. While the World Health Organization's Framework Convention on Tobacco Control recommends countries to eliminate sale of kiddie packs and single sticks, many countries have not adopted this as a policy including India. The selling of single cigarettes is well-documented in some countries.,, In Brazil, Mexico, Thailand, Uruguay, and Vietnam over one-quarter of cigarettes are purchased as single sticks. Anecdotal evidence suggests an increase in the proportion of smokers buying loose cigarettes, although there is no nationally representative estimate. This has led to a debate in recent times about the public health concerns of sale and purchase of loose cigarettes. First, this allows easy access and makes it affordable for customers, especially minors and teens, who are not able to afford the purchase of full packs and thus will increase the intensity of smoking. Second, it helps people who find it socially unacceptable to carry packs in their pockets and conceal the habit of cigarette smoking. Third, this prevents the exposure of smokers to the pictorial warnings and educational messages on the cigarette packs. For the same reason, this may negate the potential impact of plain packaging. Fourth, sale of loose cigarettes is often associated with increased price per unit (beyond the Maximum Retail Price marked on the packs) which is pocketed by the vendor and thus may result in loss of revenue to the government. Raising retail tax is one of the most effective means to reduce tobacco use and encourage smoker to quit, whereas sale of loose cigarettes may prevent effective implementation of such taxation. A 2013 report by an equity research firm states that pictorial health warnings and plain packaging pose no risk to India's cigarette companies since it is primarily a single stick market. Singles also help cigarette companies to absorb taxes and cushion any tax rise on price which is paid by smokers. Alternately, it can also be thought logically that the behavior of not purchasing cigarette packs decreases the readiness of its availability to a smoker and thus encourages moderation and reduced intensity of smoking. A study from Mexico involving patient interviews supports this hypothesis. Young adults from a disadvantaged area in the USA also indicated that they used single cigarettes as a harm reduction strategy. However, there is no published evidence on this issue till date from India.
The Global Adult Tobacco Survey (GATS), India data provides an opportunity to assess this hypothesis. In this study, we aim to assess the practice of purchasing loose cigarettes among cigarette smokers in India and determine if it is associated with the intensity of smoking.
| Materials and Methods|| |
Study design and study population
This is a secondary analysis of GATS, India survey data conducted in 2009–2010. The detailed analysis was carried out in May 2014. GATS is a cross-sectional household survey of noninstitutionalized adults population aged 15 years and above. It may be noted that the institutional population comprising those living in collective living places such as students' dormitories, hospitals, hotels, prisons, and military barracks were not included in the survey.
Data variables and definitions
Data variables were extracted from the GATS, India database and imported into EpiData (version 18.104.22.168, EpiData Association, Odense, Denmark) for data cleaning and analysis. The key outcome variable was “intensity of smoking” defined as average number of cigarettes smoked per day. This was derived from the responses to the following questions asked in the survey: “On an average how many cigarettes do you currently smoke daily?” (Code B06A) and “On an average how many cigarettes do you smoke weekly?” (Code B06A1). This was further categorised as “<10” and “10 or more” for the purpose of analysis. The key exposure variable was “practice of purchasing loose cigarettes” and was derived from response to the question (F01A), “The last time you bought cigarettes, how many did you buy?” asked in the survey. Those responded saying they bought 1–9 cigarettes were classified as having bought loose cigarettes. Those who responded as “packs” or “cartons” were classified as having bought nonloose cigarettes. The other variables extracted included age (in completed years), sex, residence, education, occupation, and wealth index. The wealth index was computed from the variables of GATS data set that captured possession of assets such as washing machine, refrigerator, and vehicle. To assign a wealth status to each household, we used standard assets based approach. We performed “principal component analysis” (PCA) to generate a wealth index score for each household on the basis their possession of assets. First component or principal component explaining maximum variability in the data was considered to assign a score to household. As the wealth score generated using PCA was a normalized score, we divided the number of households into five quintiles representing their wealth status, that is, from poorest (with minimum score) to richest (with the highest score).
Ethics issues justification
The study was exempted from ethics review by the chairperson of the Ethics Advisory Group of International Union against tuberculosis and lung disease, Paris, France as it was a secondary analysis of existing dataset and did not involve any direct interaction with human participants.
Descriptive statistical analysis was performed using EpiData software and STATA version 12.1 (Stata Corporation, Texas, USA). The proportion of buying loose cigarette among cigarette smokers was calculated. Chi-square test was used to test the association between the behavior of buying loose cigarettes and intensity of smoking. P < 0.05 was considered statistically significant. Adjusted odds ratio (OR) with 95% confidence interval (CI) were calculated as measures of association (logistic regression analysis).
| Results|| |
Out of 69,296 respondents, 11,596 smoked any tobacco product and of them 9224 smoked cigarettes. Of the latter, we could find valid information about key exposure and outcome variables under study in only 3494 cigarette smokers due to either missing values or invalid entries. Hence, data analysis in the study was done on 3494 individuals.
Prevalence of buying loose cigarettes among cigarette smokers was 56.8%. Applying this to the estimated 6.1 million smokers in India (GATS India report), it translates to 3.46 million.
The practice of buying of loose cigarette was more common among males as compared to females, and it did not vary by age and residence. The proportion of those buying loose cigarettes decreased with increasing level of education and wealth index. It was least among students as compared to other occupational categories. The socioeconomic and demographic characteristics of the proportion of buying loose cigarettes have been enlisted in [Table 1].
|Table 1: Sociodemographic characteristics of loose cigarette buyers (global adult tobacco survey India, 2009-2010)|
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The majority of respondents (85.1%) who bought loose cigarettes tend to buy <10 cigarettes a day. Over two-thirds of cigarette smokers (68.7%) who smoked <5 cigarettes per day bought loose cigarettes, whereas cigarette smokers with smoking intensity >15 per day bought more of nonloose cigarettes or packaged cigarettes (63.9%). [Table 2] shows smoking behavior among loose cigarette buyers and nonloose cigarette buyers among adults (>15 years).
|Table 2: Average number of loose cigarettes smoked per day by adults (>15 years) in 2009-2010|
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The intensity of smoking (≥10 cigarettes/day) was 70% less among loose cigarette buyers than nonbuyers (OR: 0.29, 95% CI: 0.24–0.34). It was found to be significantly lower in rural areas (OR: 0.81, 95% CI: 0.68–0.97). Even after adjusting the risk of smoking a higher number of cigarettes per day was more among males as compared to females. Loose cigarette buying practice was observed to have lesser number of cigarettes smoked daily (<10/day) among homemakers (OR: 0.63, 95% CI: 0.33–1.17) followed by students and retired/unemployed (OR: 0.83, 95% CI: 0.60–1.15). Single cigarette smoking was observed to be associated with decreased intensity among smokers who have attended formal schooling; lowest risk was seen among those who have attained education till higher secondary (OR: 0.80, 95% CI: 0.56–1.15). [Table 3] shows the logistic regression for comparing the loose cigarette buying practice with other variables adjusting for potential confounders.
|Table 3: Multivariate logistic regression analysis showing association between practice of buying loose cigarette and intensity of cigarette smoking in global adult tobacco survey India, 2009-2010|
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| Discussion|| |
This is the first study from India which provided an estimate of the practice of purchasing loose cigarettes and confirms our hypothesis that it is associated with reduced intensity of smoking. We estimated that about six in ten smokers purchased single cigarettes in their last purchase. While this comes from GATS survey and hence reflects the status at 2009–2010, it provides a useful baseline against which future trends can be assessed. Euromonitor International Tobacco report estimated that nearly 70% of all cigarettes are sold as single cigarettes in India. A jurisdiction survey from 10 jurisdictions in India in 2014 estimated that nearly 75% (59%–87%) of all cigarettes are sold as single sticks. The Euromonitor's estimate indicates an increasing trend of single cigarette sales in India. This is in contrast to a population-based study from Mexico which reported that the prevalence of buying single cigarettes at last cigarette purchase was only 10%. Another study from the United States reported a prevalence of 77% among a convenience sample of young USA adults in disadvantaged areas.
In contrast to previous studies including the one from Mexico which showed a higher prevalence of purchasing single cigarettes from younger smokers, we did not find any association with age in our study. Although, on expected lines, smokers in the higher socioeconomic status and higher education were less likely to purchase single cigarettes both in Latin Americas and our country., A contrasting feature from our study was observed among adolescent smokers of Latin America, where girls bought single cigarettes more often than boys.
Nondaily smoking has been linked with buying single cigarettes. This supports the finding in our study which shows that the average number of cigarettes smoked daily were less than five among those who purchased singles as compared to pack buyers.
Given that our study was a secondary analysis of the survey data, we could not find out the exact reasons for the practice of purchasing loose cigarettes. However, a study from Mexico had a component of focus group discussion, and it revealed some useful information. Several participants from the Mexican study reported that they began buying single cigarettes as a method to cut consumption and quitting. Further, we think that the additional effort involved in buying single cigarettes, every time and the increased unit costs act as disincentives for heavy smoking. However, a few participants in Mexican study also reported that sale of singles acted as cues to promote smoking when they wanted to quit. However, the greater price and extra effort necessary to find single cigarettes for sale may contribute to lower levels of consumption and potentially provide smokers with a harm reduction strategy that has heretofore not been considered in debates on that issue. The study from Latin America also suggested that social deprivation was strongly associated with buying single cigarettes. We further suggest exploratory studies with qualitative component to gain fair understanding of this issue in Indian context.
Our study had a few limitations, and we caution the readers to interpret the findings in light of the same. First, data were missing from nearly two-thirds of the smokers in the study and those who were included in the analysis differed significantly by age, sex, education, and socioeconomic status. Given the retrospective nature of the study, we had no way of addressing this major limitation. Second, the study used self-reported data and was cross-sectional in nature and hence we do not know if the tendency to smoke fewer cigarettes among those buying loose cigarettes will be sustained and converts into greater quit rates. This requires prospective studies with longitudinal follow-up. Third, as mentioned above, we did not have information of the exact reasons for the behavior of purchasing loose cigarettes. Fourth, we could not analyze if the behavior is different among dual users (those who smoke both bidis and cigarettes) as compared to those who smoke only cigarettes. Although it is heartening to find some evidence that purchase of singles is associated with reduced intensity of smoking, we cannot promote it as a public health strategy given the conflicting evidence if singles promote or reduce smoking. We recommend for urgent efforts to conduct high-quality studies using both quantitative and qualitative methods. Sale of singles prevents the exposure of smokers to health warnings on the packs. To address this, it may be necessary to ensure that warning on each cigarette and the possible ways of doing this need to be explored. We need to periodically monitor the sale and purchase of loose cigarettes to assess the trends of this important public health issue.
| Conclusion|| |
We found that nearly 60% of adult smokers in India purchased loose cigarettes at their last purchase and this behaviour was associated with reduced intensity of smoking. More studies are required before a concrete public health recommendation is possible.
The authors would like to thank Dr. Rana J Singh (IUATLD), Dr. Sonu Goel (SPH, PGIMER, Chandigarh) and the Union for providing the GATS data-set a constant help in creating the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Eriksen M, Mackay J, Ross H. The tobacco Atlas. 4th
ed. Atlanta, Georgia: American Cancer Society; 2013.
Yach D, Bettcher D. Globalisation of tobacco industry influence and new global responses. Tob Control 2000;9:206-16.
International Institute for Population Sciences (IIPS), Ministry of Health and Family Welfare, Government of India. Global Adult Tobacco Survey India (GATS India), 2009-2010, India. Available from: http://www.whoindia.org/en/Section20/Section25_1861.htm
. [Last accessed on 2015 Oct 01].
John S. Best Practices in Implementation of Article 13 of WHO FCTC, Case study: Kenya. Geneva: FCTC WHO Framework Convention on Tobacco Control, WHO; 2013.
Kostova D, Chaloupka FJ, Yurekli A, Ross H, Cherukupalli R, Andes L, et al.
A cross-country study of cigarette prices and affordability: Evidence from the Global Adult Tobacco Survey. Tob Control 2014;23:e3.
Linetzky B, Mejia R, Ferrante D, De Maio FG, Diez Roux AV. Socioeconomic status and tobacco consumption among adolescents: A multilevel analysis of Argentina's Global Youth Tobacco Survey. Nicotine Tob Res 2012;14:1092-9.
Thrasher JF, Villalobos V, Dorantes-Alonso A, Arillo-Santillán E, Cummings KM, O'Connor R, et al.
Does the availability of single cigarettes promote or inhibit cigarette consumption? Perceptions, prevalence and correlates of single cigarette use among adult Mexican smokers. Tob Control 2009;18:431-7.
Smith KC, Stillman F, Bone L, Yancey N, Price E, Belin P, et al.
Buying and selling “loosies” in Baltimore: The informal exchange of cigarettes in the community context. J Urban Health 2007;84:494-507.
ITC Project. ITC Mauritius National Report. University of Waterloo, Waterloo, Ontario, Canada; Mauritius Institute of Health (MIH), Pamplemousses, Mauritius; 2010.
World Health Organisation. WHO Report on the Global Tobacco Epidemic: The MPOWER Package. Geneva: World Health Organisation; 2013.
Deshmukh S, Sehgal V. IL and FS Investmart. ITC – The Mammoth Rules; 2008.
Stillman FA, Bone L, Avila-Tang E, Smith K, Yancey N, Street C, et al.
Barriers to smoking cessation in inner-city African American young adults. Am J Public Health 2007;97:1405-8.
Euromonitor International. Tobacco India Report; 2012. Available from: http://www.euromonitor.com
. [Last accessed on 2015 Oct 01].
Lal P, Kumar R, Ray S, Sharma N, Bhattarcharya B, Mishra D, et al.
The single cigarette economy in India – A back of the envelope survey to estimate its magnitude. Asian Pac J Cancer Prev 2015;16:5579-82.
Sacks R, Coady MH, Mbamalu IG, Johns M, Kansagra SM. Exploring the next frontier for tobacco control: Nondaily smoking among New York City adults. J Environ Public Health 2012;2012:145861.
Royal College of Physicians. Harm Reduction in Nicotine Addiction: Helping People Who Can't Quit. London: RCP; 2007.
[Table 1], [Table 2], [Table 3]