Multilevel geographic determinants of smoking and smokeless tobacco use among young men in India: evidence for targeted addiction prevention policies.

BACKGROUND

Tobacco use among youth in low- and middle-income countries (LMICs), particularly India, remains a critical public health challenge. However, limited research has examined how different geographic determinants distinctly contribute to smoked and smokeless tobacco use among young men in India.

METHODS

This study utilized data of 31,070 young men aged 15-24 years (urban = 7784, rural = 23,286) from the National Family Health Survey (NFHS-5, 2019-21). Four-level random intercept logistic regression models (individual, community, district, state) were employed separately for smoked tobacco, smokeless tobacco (SLT), and any tobacco use. Variance partitioning coefficients (VPC) with 95% confidence intervals quantified the proportion of variation attributable to each geographic level, adjusting for background characteristics. Sampling weights were applied for prevalence estimation.

RESULTS

Overall prevalence was 22.5% for any tobacco, 15.2% for SLT, and 11.6% for smoked tobacco, with higher rates in rural areas (25.1%, 17.8%, 12.2% respectively). State-level variation was substantial, ranging from 1.4% (Puducherry) to 49.0% (Meghalaya) for any tobacco use. Variance partitioning revealed distinct geographic patterns: PSU-level factors dominated for smoked tobacco (VPC = 58.2%, 95% CI: 55.1-61.2%), while state-level factors predominated for SLT (VPC = 53.1%, 95% CI: 50.3-55.9%). Urban-rural differences showed stronger PSU influence in urban areas for smoking (VPC = 62.0% vs. 51.0% rural), and stronger state-level influence in rural areas for SLT (VPC = 55.4% vs. 48.2% urban).

CONCLUSION

Tobacco use among young Indian men exhibits substantial multilevel geographic variation with distinct patterns for smoked versus smokeless products. Effective youth tobacco control requires coordinated multi-level strategies-community-based programs for smoking prevention and state-level policies for SLT control-rather than one-size-fits-all approaches.