Introduction

Globally, tobacco use is one of the greatest public health threats. The rampant use of various tobacco products is a matter of concern in low-and middle-income countries (LMICs). Evidence suggests that almost 1.3 billion people use tobacco globally, out of which 80% live in LMICs, where tobacco-related morbidities and mortality are highest [1]. Among LMICs, India is the second-largest consumer and still a large-scale producer of tobacco products [2,3]. The tobacco ecosystem in India is complex [4]. According to Global Adult Tobacco Survey-2 (GATS-2, 2016–17), there were nearly 267 million tobacco users aged ≥15 years in India, and among them, about 42.4% were men, and 14.2% were women [5].

Tobacco is commonly used in two ways, i.e., smokeless and smoking form. Due to socio-cultural acceptability, smokeless tobacco (SLT) use is highly prevalent in India, which includes chewing tobacco such as khaini, gutkha, betel quid with tobacco, mishri, gul, and gudakhu [6]. Other forms include smoking (cigarette, hookah, and bidi) and the use of any form of tobacco, which simultaneously predisposes a risk of oral submucous fibrosis (OSMF), a premalignant disorder with potency to transform into oral cancer [7]. Evidence supports that smoking is responsible for health ailments of the cardiovascular and respiratory systems [6]. Tobacco not only results in loss of lives but also levies associated social and economic costs. In India, the total financial cost of tobacco uses for all illnesses during 2017–18 among people aged ≥35 years is approximately INR 177 billion (US $ 27.5 billion) [8].

India is a diversified land of many cultures and ethnic groups with one of the largest tribal populations in the world. According to the Census of India-2011, the scheduled tribes (STs) comprised around 104 million people, 8.6% of the national population [9]. There are 550 tribes in India, including particularly vulnerable tribal groups (PVTGs). Approximately 90% of the country’s tribal population lives in rural areas, while the remaining 10% resides in urban areas [10]. Still, a gap exists between the indigenous and non-tribal people as the former prefer to live in their geographical habitats, which are often secluded in forests and hard-to-reach areas. Their culture and traditions broadly vary, which disintegrates them from mainstream socio-economic activities; a life often marred with subsistence-based existence, invariably leading to their lower education (41% with no formal education) and socio-economic attainment (41% below the poverty line) [11]. This social exclusion often compels these marginalized communities to have disparities in accessing public health services.

Moreover, deleterious habits such as tobacco use are deeply rooted in their social beliefs and cultural practices. It often remains entrenched in their practices which is difficult to mould. As per the social affirmation and traditional practices, the pervasiveness of tobacco consumption is quite apparent. For instance, SLT is wrongly perceived as safer than smoking, resulting in higher consumption, early initiation, and persistence as a norm [12,13]. Among the indigenous communities, mortality, morbidity, and malnutrition rates are still higher than the average Indian population due to various barriers such as language, education, and infrastructural advancements [14].

Since ancient times, the habitual consumption of tobacco has been an eminent practice among tribal communities [15]. Tobacco uses among the general population is widely studied based on the Global Youth Tobacco Survey (GYTS) and Global Adult Tobacco Survey (GATS). However, it is scarce in the context of the tribal population [16,17]. Most of the evidence on tobacco use among tribes is either from a specific region or based on a survey from a particular tribe with no nationally representative study. Even within tribals, the available evidence largely focuses on adolescents or young adults, with limited literature on the aging population. Considering the large tribal population in India and their unique health-related behaviours, it is pertinent to generate evidence on tobacco use among this community to pave the way for future tobacco control programs and policies targeting this marginalized group. Hence, we aimed to estimate the prevalence of tobacco use, and assess its determinants and regional variations among older tribal adults in India using nationally representative data.

Materials and methods

Study participants and sample size

An individual survey schedule was employed among 72,250 participants aged ≥45 years. Participants who referred to their caste as "Scheduled tribes" (STs) were included in this study. Following this, the conclusive sample size of 11,365 tribal individuals aged ≥45 years was achieved as per the objective of this study (Fig 1).

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Fig 1. Selection of study population.

https://doi.org/10.1371/journal.pone.0282487.g001

Results

For this analysis, 11,365 scheduled tribe participants aged 45 years and above were included. Their average age was 59.3 (±10·7) years. Most of them belonged to the age group of 45–59 years (54.5%). A nearly equal number of male and female interviewees were included, with a little female predilection (53.7%). Most of the tribal population never went to school (54.6%) and lived in rural settings (77.4%). Most of the participants were physically inactive (52.6%) and worked (56.2%) while interviewed (Table 1).

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Table 1. Sociodemographic characteristics of study population (n = 11,365).

https://doi.org/10.1371/journal.pone.0282487.t001

The overall prevalence of tobacco use was 46.1%, while smoking and SLT use was estimated 18.6% and 31.7%, respectively; tobacco in both forms (dual-use) was consumed by 4.2% of the participants. Smoking and SLT use were more prevalent among males (smoking: 34.8% and SLT: 40.1%) (Fig 2).

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Fig 2. Type of tobacco consumption across gender among the tribal populations.

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The prevalence of smoking and SLT use was estimated the highest (23.7% and 38.4%, respectively) among the population aged 75 years and above. Smoking (24.1%) was most prevalent in tribals from southern India, while the eastern tribal population predominantly used SLT (48.6%). The prevalence of any form of tobacco use among the four most tribal populated states Madhya Pradesh, Maharashtra, Odisha, and Rajasthan were 39%, 43%, 61%, and 46%, respectively (Fig 3). The detailed state-wise prevalence of various forms of tobacco is presented in S3 Table.

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Fig 3. Prevalence of different forms of tobacco use across major tribal populated states.

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Tobacco use of any variant was relatively higher among alcohol consumers (smokers: 32.9%, SLT use: 52.5%, and any form of tobacco use: 75.8%). The physically active participants used tobacco of any form more (smokers: 20.0%, SLT use: 36.8%) than those who were not into sports or regular physical work (smokers: 17.3% and SLT use: 26.3%). The detailed distribution of tobacco use is provided in Table 2.

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Table 2. Prevalence of various forms of tobacco and its univariate association with socio-demographic characteristics.

https://doi.org/10.1371/journal.pone.0282487.t002

Univariate logistic regression models identified participants aged 75 years and above, males, rural residents with lesser years of schooling, currently working, living with a spouse, and alcohol use were associated with tobacco use (Table 2). Table 3 shows the association of socio-demographic and behavioral factors with different forms of tobacco use among the study population after adjusting for all the covariates. There was a 76% greater likelihood of tobacco use among the 75+ age group (AOR: 1.76 (1.25–2.46). Males were highly associated with using all forms of tobacco (smoking, SLT, or any form) compared to females. Relatively higher odds of smoking were evident from the central [AOR: 1.45 (0.91–2.31)] and southern [AOR: 1.20 (0.73–1.97)] tribal population; however, SLT was highly associated with the eastern [AOR: 6.17 (3.88–9.80)] and western region [AOR: 4.01 (2.49–6.44)]. Alcohol was found to be an attributing factor for any form of tobacco, i.e., smoking [AOR: 2.09 (1.69–2.58)] or SLT [AOR: 3.05 (2.54–3.66)] or any form of tobacco [AOR: 4.06 (3.39–4.87)]. Physical activity was associated with SLT [AOR: 1.33(1.09–1.63)] and any tobacco use [AOR: 1.27 (1.05–1.52)]. The odds of SLT use were 41% higher among the poorest group [AOR: 1.41 (1.04–1.92)].

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Table 3. Multivariable association between various forms of tobacco with socio-demographic characteristics.

https://doi.org/10.1371/journal.pone.0282487.t003

Discussion

This study reported the prevalence and determinants of tobacco use among older adults from indigenous communities of India using nationally representative data. Overall, 46 percent of tribal population was estimated using any form of tobacco, with 19 percent smokers and approximately 32 percent SLT users. Those who were male had no formal education, and consumed alcohol were found to be highly associated with smoking. On the other hand, individuals over the age of 75, male, residing in the eastern region, and reported to consume alcohol were linked with the use of SLT. The male tribal population, those having no formal education, those who consumed alcohol, and those belonging to the eastern region were more likely to use any form of tobacco.

The overall prevalence of tobacco observed in our study is consistent with a study from Madhya Pradesh, which found that tobacco was used by 48.1% of urban tribal people aged 40–65 years [22]. Here, it is worth noting that the prevalence of tobacco use among tribes is much higher than that of the general population (28.6%) in India, as reported by GATS-2 [5].

In comparing the prevalence of tobacco use from LASI (2017–18) and GATS-2 (2016–17), we found that in GATS-2, the prevalence of smoking was 28.6%, and SLT was 23.5% among the 45–59 years, age group. However, in our study, the prevalence of smoking was 17%, and SLT use was 31.2% among the same age group, which indicates a reduction in the use of smoking tobacco. Still, an increase in the use of SLT was observed [23].

Another study conducted among the Gond tribe in central India observed the prevalence of smoking to be around 22% which is in harmony with the findings of our study [24]. In contrast to the prevalence of SLT use estimated in this study, a study conducted among indigenous communities of Kerala observed the prevalence of SLT use to be around 92% [14]. A probable reason for higher SLT use among tribes could be the socio-cultural acceptance as a part of custom and perceived health benefits of SLT use compared to smoking. Nonetheless, almost half of the sample tribal population consumed nicotine, which may lead to deleterious effects on the oral cavity, respiratory, and cardiovascular systems [25].

We identified older age to be an essential predictor of tobacco use among tribal communities, which is consistent with findings of a study among a nationally representative population using GATS and GYTS that reported tobacco dependency was highest among individuals aged ≥45 years [26]. In our analysis, male participants were more likely to use tobacco than their female counterparts, similar to a study conducted among various tribes of Kerala [27]. A study conducted among the general population indicated that smoking was more prevalent among males. Conversely, smokeless tobacco usage was observed to be more common among females, indicating differences in the factors that determine tobacco usage being different among different groups [23]. Additionally, the study found a correlation between tobacco usage and lower levels of educational attainment. Smoking tobacco was more common among those who did not have formal education, whereas participants who completed primary education were more frequent users of the SLT. These findings are similar to a study conducted among urban tribal people in Madhya Pradesh, which reported maximum tobacco consumption among participants with lesser years of schooling [22].

Our study revealed that individuals who engaged in physical activity were more prone to consume SLT and any tobacco product in comparison to those who didn’t. However, Jeon et al. (2021) discovered that there were marked differences in physical fitness between smokers and non-smokers, with the latter having a higher level of physical capability [28]. We found smoking was insignificantly associated with physical activity which was inconsistent with the results of a study conducted by Cram et al. (2014) found that individuals who smoked and were less physically active tended to have poor health outcomes in the population [29].

Tribal individuals belonging to higher MPCE quintiles were found to have a greater risk of smoking. However, a review suggested smoking to be higher in the medium MPCE quintiles group of the general population [13]. It also reported that SLT use in India was more among the lowest MPCE quintile class [13]. We observed tobacco use was associated with the simultaneous use of alcohol among our study participants [30]. A recent meta-analysis reported that the synergistic consumption of any form of tobacco with alcohol is significantly associated with a higher risk of oral squamous cell carcinoma [31]. NFHS-5 (2019–2021) a nationally representative survey, suggests that tobacco prevalence was higher in Northeastern states. Our present study also observed a higher odds of SLT and any form of tobacco use in the eastern region. NFHS-5 showed a decline in tobacco use prevalence among most of the states except Bihar, Himachal Pradesh, and Mizoram, where still an uptrend can be seen [32]. We also estimated a higher tobacco burden in states such as Bihar, West Bengal, Jharkhand, and Odisha in the present study. A study conducted by Yadav et al. (2020) to evaluate the burden of SLT use indicates that the prevalence in eastern states, Bihar (23.5%), Jharkhand (35.4%), and Odisha (42.9%) was higher than the national average (21.4%), whereas in West Bengal (20.1%) it is less than the national average [33]. This could be due to various factors including family environment (as the child learns from immediate family members), and social traditions, both containing the elements that promoted tobacco use [34]. The peer pressure, easy access to tobacco and gutkha at shops nearby, and the absence of opposition from the parents, or other family members likely contributed to tobacco use [34–36]. Additionally, tobacco is used as a mean to concentrate on work [37]. A study conducted by Nanda et al. among Donghria Kondhs tribes in Odisha showed that tobacco is used to reduce abdominal pain during menstruation [38]. These are some of the driving factors that influence tobacco use among tribals. The regional differences emphasize further strengthening of tobacco control programs and policies with a focus on the eastern tribal populations.

Even though tobacco is banned in most states, the prevalence of tobacco consumption is still high in Bihar and Odisha, as evidenced by our findings. The Jharkhand Government, in a recent order, has banned the consumption of any form of tobacco products for all State Government employees from 01 April 2021. Such initiatives should be taken in all other states for tobacco control.

Several existing tobacco control programs and policies, such as the National Tobacco Control Programme (NTCP) and The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, COTPA, 2003, have been effective in reducing the burden of tobacco in India [39]. SLT taxation as a policy imperative remains an under-researched area and needs further attention from researchers and policymakers for effective outcomes [40]. Still, a wide gap exists between the burden of tobacco consumption among tribes and the general population. Our study reflects the prevalence of tribal tobacco use is higher than the average national use, which calls for urgent action in the tribal-dominated regions [5]. The existing programs should be tailored so that they are culturally acceptable and linguistically understandable among these groups, which can help create a positive effect.

Conclusion

This study highlights the high burden of tobacco use along with its social determinants, which can help in tailoring the tobacco control program among tribes in India. Tobacco control policies should target males, rural residents, individuals without formal education, and alcoholics. Regional variations should be managed by adopting good practices of regions with higher tobacco control. Tobacco control measures should be prioritized in high-burden states such as Bihar, Jharkhand, Odisha, and West Bengal. Future studies should explore the behavioural and social linkages to tobacco use among tribals.

Supporting information

Acknowledgments

The authors are grateful to the Longitudinal Ageing Study in India (LASI) for assembling and publishing accurate, nationally representative data on a range of health, biomarkers, and healthcare utilization indicators for the population in the age range of 45 years and older. The authors are also grateful to LASI’s project partners, the International Institute for Population Sciences (IIPS), Harvard T. H. Chan School of Public Health (HSPH), and the University of Southern California (USC).