Rural-Urban Inequalities in Lifetime Tobacco Consumption Among Middle-Aged and Older Adults in India: A Decomposition Analysis Using Survey-Weighted National Data

IntroductionTobacco consumption was leading global risk factor for mortality in 2023. This study aimed to assess rural-urban inequalities in lifetime tobacco consumption among Indian adults aged 45 years and above, alongside socioeconomic inequalities. METHODS: Data from the Longitudinal Ageing Study in India (2017-18, Wave-1) were analyzed, focusing on participants aged >45 years. Weighted prevalence estimates and chi-squared tests were utilized to compare tobacco use across groups. Socioeconomic disparities were examined using the concentration index, and multivariate decomposition analysis identified the contribution of socioeconomic, demographic, health-related, and behavioral factors to rural-urban differences in tobacco consumption. RESULTS: Overall, 36.78% of middle-aged and older adults (45 years and above) reported tobacco use, with a rural-urban gap of 17.72%. Smokeless tobacco (19.88%) was more prevalent than smoking (13.92%), and 2.98% used both forms. The rural-urban gap was greater for smokeless tobacco (9.54%) than for smoking (6.06%). The Northeast region showed the highest prevalence of any tobacco use (54.29%), smokeless (36.65%), and dual use (5.88%), while the North had the highest smoking rates (24.56%). Socioeconomic disparities were more pronounced in urban areas, with higher tobacco use among poorer groups. Compositional factors explained 58% of the rural-urban difference, primarily driven by education (24.74%), region (17.43%), and alcohol use (11.30%). This indicates that if urban and rural areas had the same educational characteristics, regional distribution and prevalence of alcohol consumption, the difference tobacco consumption would decrease by 53.47%. CONCLUSION: Tobacco consumption is more prevalent in rural and economically disadvantaged populations. Strengthening National Tobacco Control Program (NTCP) implementation, particularly in rural and Northeastern regions, and addressing socioeconomic determinants are crucial to reducing tobacco use and narrowing rural-urban disparities.