PONE-D-24-52387Relationship Between Tobacco Use and Body Mass Index Among Indian Adults- Findings of National Family and Household Survey (NFHS-5)PLOS ONE

Dear Dr. Goel,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Dear Authors,

The reviewers have a mixed response to the manuscript. You are requested to kindly go through the suggestions, especially reviewer number 3 and submit the revised version for further consideration.

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Academic Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

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4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is my review for the manuscriopt"Relationship Between Tobacco Use and Body Mass Index Among Indian Adults- Findings of National Family and Household Survey (NFHS-5)"

Dear authors,thank you for your effort, it's a very good research

- key words: Body mass index must be add.

-In table 1 and 3: regarding the categories of obesity, I think that underweight will be better than undernourished

-I think the recommendation section need to be more comperhensive and directed to the practical implication of the findings.

Reviewer #2: The study has various strengths with the large sample size and using robust and standardized data collection methodology and analysis, which makes it scientifically sound to draw the conclusions. However, one concern I have is that the study sample is 87.8% female and 12.2% male. This skew in the gender proportion from the general population can affect the generalizability of the study findings. As it is not possible to amend this at this stage, it should be mentioned in the limitation.

Second, although the main finding and conclusion of the paper highlights the BMI-lowering effect of tobacco, the conclusion should also address (both in the main paper and in the abstract), the finding of the high prevalence of obesity/overweight in the smoker group with some further analysis.

Reviewer #3: General Comments:

The authors have undertaken an important analysis using NFHS-5 data to explore the association between tobacco use and BMI. While the study presents valuable insights, there are several areas where the manuscript can be improved to enhance the clarity, robustness, and validity of the findings.

Specific Comments:

1) The manuscript would benefit from a clear flow diagram outlining the sample selection process, particularly in categorizing tobacco users by type of tobacco used.

2) The official NFHS-5 report (Chapter 11, Page 445) states that 39% of men and 4% of women aged 15-49 use any form of tobacco. However, the authors report a tobacco use prevalence of approximately 7%. This discrepancy needs to be clarified, as it raises concerns about data accuracy and representativeness.

3) The comparison should be made primarily among men due to the more balanced distribution of tobacco users and non-users in this group.

4) The NFHS-5 report explicitly states that tobacco use decreases with increasing wealth quintiles. Specifically, 22% of men in the highest wealth quintile use tobacco, compared to 59% of men in the lowest quintile. Additionally, 9% of women in the lowest wealth quintile use tobacco. These socioeconomic patterns must be considered when interpreting the relationship between tobacco use and undernutrition.

5) A more robust statistical approach is required to control for potential confounders that influence BMI independently of tobacco use.

6) Given the large NFHS-5 sample size, Propensity Score Matching (PSM) should be considered, matching participants by residence (urban/rural), income quintile, age group, and educational level to strengthen causal inference.

7) Alcohol consumption should be included as a covariate, as tobacco use and alcohol consumption are often correlated. Controlling for alcohol use will help isolate the effect of tobacco on BMI.

8) The approach of first classifying individuals into underweight, normal, and overweight categories and then examining tobacco use patterns suggests potential reverse causality or selection bias. Instead, the authors should compare BMI between tobacco users and non-users before categorizing BMI.

9) In Table 2, the analysis within tobacco users categorized as normal, underweight, and overweight is less informative. A more appropriate comparison would be between tobacco users and non-users, as tobacco use itself can act as a confounder.

10) The authors should provide regression model results with and without tobacco use as an independent variable. A supplementary table should illustrate how the inclusion of tobacco use affects BMI estimates, allowing readers to assess its actual contribution.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes:  Nebyu Amaha

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Relationship Between Tobacco Use and Body Mass Index- A Propensity Score Matching Analysis of an Indian National Survey

PONE-D-24-52387R1

Dear Dr. Goel,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Yogesh Kumar Jain, MPH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: All comments have been addressed

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Yes

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: I Don't Know

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: No

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Dear authors; Thank you for addressing all comments. Wishing you all luck in this research and all future work

Reviewer #2: I confirm the author has incorporated both comments I have provided. They have indicated the skewed gender distribution as a limitation. They have also highlighted the additional finding of the high prevalence of obesity/overweight in the smoker group in addition to the main conclusion of the BMI-lowering effect of tobacco.

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7. PLOS authors have the option to publish the peer review history of their article (what does this mean? ). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy .

Reviewer #1: No

Reviewer #2: Yes:  Lia Tadesse Gebremedhin

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