Tobacco and Alcohol Associated Mortality among Men by Socio-Economic Status in India

Abstract

Background: Tobacco use, alcohol use and Socioeconomic status (SES) are all strongly associated
with mortality. These risk factors however, are also strongly associated with each
other. The effect of the interrelationship between these risk factors on mortality has not been
examined in India.
Objectives: To study tobacco and alcohol associated Hazard Ratios (HRs) stratified by SES.
Methods: A cohort of 34,055 men (age>=45 years) was recruited through house visits and information
collected through face-to-face interviews during 1994 to 1997. During 1999 to 2003,
follow-up through repeat house visits was conducted and deaths were recorded. Education
level was used as proxy for SES. Cox proportional hazards model provided HRs and 95% Confidence
Intervals (CIs) for tobacco/alcohol associated mortality adjusted for alcohol/tobacco
and other confounders. Additionally, HRs was stratified by SES for their individual (tobacco,
alcohol use) and their joint effect on mortality.
Results: For tobacco associated mortality, stratification by SES showed higher HRs for high
SES bidi smokers (HR=2.01) compared to corresponding low SES bidi smokers (HR=1.41).
For alcohol associated mortality, HRs were higher among high SES ‘country/desi’ drinkers
(HR=1.56) compared to corresponding low SES counterpart (HR=1.31). After adjusting for
alcohol exposure, the highest attenuation of HRs (>20%) for tobacco associated mortality was
observed for deaths from tuberculosis and digestive system diseases (mainly liver diseases)
among various forms of tobacco users.
Conclusions: The examination of differences in mortality risks by SES, showing higher HRs
among high SES bidi smokers and high SES ‘country/desi’ drinkers, have implications for
public health policies.