Global Adult Tobacco Survey (GATS): A Case for Change in Definition, Analysis and Interpretation of “Cigarettes” and “Cigarettes Per Day” in Completed and Future Surveys

Background: The Global Adult Tobacco Survey has 15 key indicators, cigarettes smoked per day (CPD)among daily smokers being one of them. The first wave of GATS in 14 countries indicated that mean CPD use ishigher in women than men in India only, which is contrary to the current understanding of tobacco use globally.This study was undertaken to understand the unusual findings for mean CPD use in the GATS-India survey.Materials and
Methods: Items B06a and B06b of the GATS India survey questionnaire that collected informationon daily consumption of manufactured and rolled cigarettes were analyzed using SPSS software. Exclusive userswere identified from these items after excluding the concurrent users of other tobacco products. Cigarette type,exclusive use and gender stratified analyses were made. Consumption of different types of cigarettes among themixed users of manufactured and rolled cigarettes were correlated.
Results: Higher mean number of CPD useamong male daily-smokers was observed than their female counterparts in product specific analysis. Mean CPDas per GATS cigarette definition was higher in males than females for exclusive users but a reverse trend wasobserved in case of non-exclusive users. Use of manufactured cigarettes increased with increase in use of rolledcigarette among the mixed users and around half of these users reported equal CPD frequency for the both typesof cigarettes.
Conclusions: The anomaly in mean CPD estimate in GATS-India data was due to inclusion of twoheterogeneous products to define cigarettes, variation in cigarette product specific user proportions contributingto the average and non-exclusive concurrent use of other tobacco products. The consumption pattern of cigarettesamong the mixed users highlights bias in CPD reporting. Definition, analysis and interpretation of ‘cigarettesper day’ in the GATS India survey need to be improved by redefining cigarettes and making product specificanalyses.