Smoking, educational status & health inequity in India

Health related behaviours, especially smoking and tobacco use, are major determinants of health and lead to health inequities. Smoking leads to acute respiratory diseases, tuberculosis and asthma in younger age groups and non communicable diseases such as chronic lung disease, cardiovascular diseases and cancer in middle and older age. We observed an inverse association of educational status with tobacco use (smoking and other forms) in western Indian State of Rajasthan. In successive cross-sectional epidemiological studies- the Jaipur Heart Watch (JHW)- in rural (JHWR; n=3148, men=1982), and urban subjects: JHW-1 (n=2212, men=1415), JHW-2 (n=1124, men=550) and JHW-3 (n=458, men=226), we evaluated various cardiovascular risk factors. The greatest tobacco consumption was observed among the illiterate and low educational status subjects (nil, 1-5, 6-10, >10 yr of formal education) as compared to more literate in men (JHW-R 60, 51, 46 and 36% respectively; JHW-1 44, 52, 30 and 18% JHW-2 54, 43, 29 and 24%; and JHW-3 50, 27, 25 and 25%) as well as women (Mantel Haenzel test, P for trend <0.05). In the illiterate subjects the odds ratios (OR) and 95 per cent confidence intervals (CI) for smoking or tobacco use as compared to the highest educational groups in rural (men OR 2.68, CI 2.02, 3.57; women OR 3.13, CI 1.22, 8.08) as well as larger urban studies- JHW-1 (men OR 2.47, CI 1.70, 3.60; women OR 13.78, CI 3.35, 56.75) and JHW-2 (men OR 3.81; CI 1.90, 7.66; women OR 13.73, CI 1.84, 102.45) were significantly greater (P<0.01). Smoking significantly correlated with prevalence of coronary heart disease and hypertension. Other recent Indian studies and national surveys report similar associations. Health ethicists argue that good education and health lead to true development in an underprivileged society. We propose that improving educational status, a major social determinant of health, can lead to appropriate health related behaviours and prevent the epidemics of non communicable diseases in developing countries.