Title: Variations in the patterns of tobacco usage among Indian Females - findings from the
Global Adult tobacco Survey India
Version: 3 Date: 04 May 2022
Reviewer's report:
1. SUMMARY AND OVERALL IMPRESSION
This paper summarizes results from the Global Adult Tobacco Survey-Round 2 (GATS-2) in
India (2016-17) specifically on women, through an independent statistical analysis, showing
the pattern of use according to socioeconomic variables. Other influential factors shown
are knowledge of the harms of tobacco, having noticed pack warnings, intention to quit
and influencing factors. The paper shows that younger age, higher education status, self-
employment, buying whole bidi or cigarette packs (not loose -and therefore seeing pack
warnings) were associated with intention to quit. Since few will read the lengthy GATS report
found only on specific websites, more may read a journal article on GATS2 data on specific
variables.  This manuscript has its strengths, but also has its weaknesses. I think it could be
revised to make it more clear.
STRENGTHS:
a. The focus on women with regard to tobacco use and SHS exposure broadens the literature.
b. Some good literature cited in the introduction places the Indian tobacco use situation in a
global context
c. The mention in the introduction of specific health risks women face who use tobacco helps
to strengthen the rationale for the study
d. Objectives – the research questions were clear
e. In methods, a good choice of variables for analysis was made.
f. The results overall show clear patterns of tobacco use and second-hand smoke (SHS) exposure
with socio-economic variables. This information can be used in interventions to increase public
awareness of the harms of tobacco use and increase the motivation to quit, as implied.
WEAKNESSES:
a. The first paragraph, in the introduction, is a bit confusing, apparently due to an interpretation
of results in the WHO report (1st reference). I suggest having another look at that. It shows that
in all continents tobacco use is currently declining.
b. The dataset reported to have been analyzed is incorrect under the Data Availability
Statement. It would be GATS-2 not DHS.  It is available from: https://nccd.cdc.gov/
GTSSDataSurveyResources/Ancillary/DataReports.aspx?CAID=2
c. The study claims to compare non users with ever users, which would be wrong methodology,
however the actual calculations are for never users and ever users, which  actually was a correct
comparison. Best to re-word that.
d. Use of a few older references, such as reference no. 2 (Amos, 1996) is creating confusion
between the past (increasing prevalence of tobacco use) and the present (decreasing use).
e. The mention of many other countries tends to take the reader’s attention away from the topic
at hand and raises other questions. This could be minimized to the extent needed to create a
global context.
f. Use of the word "noticeability" is used with reference to pack health warnings themselves.
When referring to women who notice them it would be better to say "noticed." These refer to
two different issues: noticeability depends on the quality and placement of the pack warning and
noticing is the ability of the person buying tobacco to see and understand the warning. The latter
of course depends on education level, clarity of the image and language of the text warning to
the person,  and whether the person buys a whole pack carrying a warning or a loose product.
The two concepts are of course inter-related.
g. Short Title: Trends of tobacco consumption among Indian women
The word trends in the short title implies changes over time, which are not being described in
the paper – a better word could be “Patterns.”
SHARING A REFERENCE:
A good reference that shows the previous increase and the later decrease in tobacco use is the
following:
Suliankatchi Abdulkader R, Sinha DN, Jeyashree K, Rath R, Gupta PC, Kannan S, Agarwal
N, Venugopal D. Trends in tobacco consumption in India 1987-2016: impact of the World
Health Organization Framework Convention on Tobacco Control. Int J Public Health. 2019
Jul;64(6):841-851. doi: 10.1007/s00038-019-01252-x. Epub 2019 May 28. PMID: 31134319.