Extending Application of the 'Hardcore' Definition to Smokeless Tobacco Use: Estimates from a Nationally Representative Population in India and its Implications

  • Jena, Pratap Kumar (Public Health Foundation of India) ;
  • Bandyopadhyay, Chandan (SIM Solutions) ;
  • Mathur, Manu Raj (Public Health Foundation of India) ;
  • Das, Sagarika (Central Institute of Psychiatry)
  • Published : 2012.12.31


Background: The term 'hardcore' has been applied to use of smoking tobacco and generally referred to as the inability or unwillingness of regular smokers to quit. The component constructs of hardcore except nicotine dependence are product neutral. With the use of 'time to first chew' as a measure of nicotine dependence, hardcore definition can be extended to characterize smokeless tobacco users. Hardcore users respond less to tobacco cessation interventions, and are prone to tobacco induced diseases including cancer. Thus identifying hardcore users would help in estimate the burden of high risk population for tobacco induced diseases. Smokeless tobacco use is predominant and accounts for more than 50% of oral cancer in India. Hence, hardcore chewing information could be used for planning of tobacco and cancer control interventions. The objective of this study was to assess the prevalence and associated factors of hardcore smokeless tobacco use in India. Materials and Methods: Global Adult Tobacco Survey (GATS)-India 2010 data were analyzed to quantify hardcore smokeless tobacco use in India with following five criteria: (1) current daily smokeless tobacco use; (2) no quit attempt in the past 12 months of survey or last quit attempt of less than 24 hours duration; (3) no intention to quit in next 12 months or not interested in quitting; (4) time to first use of smokeless tobacco product within 30 minutes of waking up; and (5) knowledge of smokeless tobacco hazards. Results: The number of hardcore smokeless tobacco users among adult Indians is estimated to be 5% (39.5 million). This group comprises 23.2% of daily smokeless tobacco users. The population prevalence varied from 1.4-9.1% across different national regions of India. Logistic regression modeling indicated age, education and employment status to be the major predictors of hardcore smokeless tobacco use in India. Conclusions: The presence of a huge number (39.5 million) of hardcore smokeless tobacco users is a challenge to tobacco control and cancer prevention in India. There is an unmet need for a universal tobacco cessation programme and intensification of anti-tobacco education in communities.


Hardcore users;smokeless tobacco;dependence;India


  1. Jarvis MJ, Wardle J, Waller J, Owen L (2003). Prevalence of hardcore smoking in England, and associated attitudes and beliefs: cross sectional study. Bri Med J, 326, 1061.
  2. Jayakrishnan R, Mathew A, Lekshmi K, et al (2012). Assessment of Nicotine Dependence among Smokers in a Selected Rural Population in Kerala, India. Asian Pac J Cancer Prev, 13, 2663-7.
  3. Jena PK, Kishore J (2012). Prevalence and correlates of hardcore smoking in india. research and reviews. A J Med, 2, 16-24.
  4. Kotz D, West R (2009). Explaining the social gradient in smoking cessation: It's not in the trying, but in the succeeding. Tobacco Control, 18, 43-6.
  5. Lichtenstein E, Keutzer CS (1973). Implications of Psychological research for smoking control clinics. Hlth Service Report, 99, 535-40.
  6. Lund M, Lund KE, Kvaavik E (2011). Hardcore smoking in Norway 1996-2009. Nicotine and Tobacco Res, 13, 1132-9.
  7. MacIntosh H, Coleman T (2006). Characteristics and prevalence of hardcore smokers attending UK general practitioners. BMC Family Practice, 7, 24.
  8. Ministry of Health and Family Welfare (2010). Global Adult Smoking Survey (GATS)-India, 2009-10. Ministry of Health and Family Welfare, Govt. of India, New Delhi.
  9. Pierce JP, Farkas AJ, Gilpin EA (1998). Beyond stages of change: the quitting continuum measures progress towards successful smoking cessation. Addiction, 92, 277-86.
  10. Reddy KS, Gupta PC (Editors) (2004). Report on Tobacco Control in India. Ministry of Health and Family Welfare, Government of India, New Delhi.
  11. Reid JM, Hammond DP, Driezen PM (2010). Socio-economic status and smoking in Canada, 1999-2006: has there been any progress on disparities in tobacco use? Canadian J Public Hlth, 101, 73.
  12. Schaap MM, van Agt HM, Kunst AE (2008). Identification of socioeconomic groups at increased risk for smoking in European countries: Looking beyond educational level. Nicotine and Tobacco Res, 10, 359-69.
  13. Schmahl D, Lichtenstein E, Harris DE (1972). Successful treatment of habitual smokers with warm, smoky air, and rapid smoking. J Consult Clin Psychol, 38, 105-11.
  14. Velicer WF, Rossi JS, Prochaska JO, DiClemente CC (1996). A criterion measurement model for health behavior change. Addictive Behaviors, 21, 555-84.
  15. Warner KE, Burns DM (2003). Hardening and the hard-core smoker: Concepts, evidence, and implications. Nicotine and Tobacco Res, 5, 37-48.
  16. Boffetta P, Hecht S, Gray N, Gupta P, Straif K (2008). Smokeless tobacco and cancer. Lancet Oncol, 9, 667-75.
  17. Augustson EM, Marcus SE (2004). Use of the current population survey to characterize subpopulations of continued smokers: A national perspective on the "hardcore" smoker phenomenon. Nicotine and Tobacco Res, 6, 621-9.
  18. Augustson EM, Barzani D, Rutten LJF, Marcus S (2008). Gender differences among hardcore smokers: an analysis of the tobacco use supplement of the current population survey. J Women Hlth, 17, 1167-73.
  19. Cohen EJ, McDonald PW, Selby P (2012). Debates-Softening up on the hardening hypothesis. Tob Control, 21, 265-6.
  20. Costa ML, Cohen JE, Chaiton MO, et al (2010). "Hardcore" definitions and their application to a population-based sample of smokers. Nicotine and Tobacco Res, 12, 860-4.
  21. DiClemente CC, Prochaska JO, Fairhurst SK et al (1991). The process of smoking cessation: an analysis of precontemplation, contemplation, and preparation stages of change. J Consult Clin Psychol, 59, 295-304.
  22. Dikshit R, Gupta PC, Ramasundarahettige C, et al (2012). Cancer mortality in India: a nationally representative survey. The Lancet, 379, 1807-16.
  23. Emery S, Gilpin EA, Ake C, Farkas AJ, Pierce JP (2000). Characterizing and identifying "hard-core" smokers: Implications for further reducing smoking prevalence. Am J Public Hlth, 90, 387-94.
  24. Fagerstrom K (2003). Time to first cigarette; the best single indicator of tobacco dependence? Monaldi Arch Chest Dis, 59, 91-4.
  25. Fagerstrom KO, Kunze M, Schoberberger R, et al (1996). Nicotine dependence versus smoking prevalence: comparisons among countries and categories of smokers. Tob Control, 5, 52-6.
  26. Ferketich AK, Gallus S, Colombo P, et al (2009). Hardcore smoking among Italian men and women. Eur J Cancer Prev, 18, 100-5.
  27. Gupta PC, Mehta FS, Daftary DK, et al (1980). Incidence rates of oral cancer and natural history of oral precancerous lesions in a 10-year follow-up study of Indian villages. Commun Dent Oral Epidemiol, 8, 283-333.
  28. Gupta PC, Ray CS, Sinha DN, Singh PK (2011). Smokeless tobacco: A major public health problem in the SEA region: A review. Indian J Public Hlth, 55, 199-209.
  29. Hart J, Hyun S (2012). Cancer mortality, state mean elevations, and other selected predictors. Dose-Response, 10, 58-65.
  30. Hyunyi C, Salmon CT (2007). Unintended effects of health communication campaigns. J Communication, 57, 293-317.
  31. Ip DT, Cohen JE, Bondy SJ, et al (2012). Do components of current 'hardcore smoker' definitions predict quitting behaviour? Addiction, 7, 434-40.
  32. Irvin JE, Hendricks PS, Brandon TH (2003). The increasing recalcitrance of smokers in clinical trials II: Pharmacotherapy trials. Nicotine and Tobacco Res, 5, 27-35.

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