Abstract
Substance use is a public health concern on a global and national levels. There is a scarcity of nationally representative systematic research on the epidemiology of substance use in India. This narrative review aims to discuss the various large epidemiological surveys providing data on substance use in India. Attempts have been made to extract data pertaining to special population groups as well.
Keywords: Epidemiology, India, substance use
INTRODUCTION
Substance use is a major public health concern across the globe.[1] Both licit and illicit substances use are substantially associated with morbidity, mortality, disability, and disease burden.[2] The same is true for India as well.[3] The use of many substances is reported and has been part of Indian culture for ages. Alcohol, cannabis, and opium are mentioned in religious scriptures and are part of many religious rituals/practices across the country.[4] However, the patterns of substance use are notorious for changing over time. With the changes in Indian culture, substance use patterns have also been changing.[3,5] Though there have been some attempts to understand the burden, patterns, and trends of substance use in India, they have been limited by the scarcity of valid and reliable data on epidemiological aspects of substance use.[3,6] Hence, the previous studies relied on understanding these aspects from non-epidemiological data sources. During the last decade, multiple nationwide epidemiological surveys have been conducted.
This article provides insights into the burden, patterns, and trends of substance use (both licit and illicit) in India, relying on epidemiological surveys. Authors have tried to restrict to only national epidemiological data to draw valid and reliable conclusions. For the sake of convenience, we have provided the brief methodology of each of the surveys first. Then, we discuss the general population data followed by substance use in special populations such as children and adolescents, women, the elderly, and People Who Inject Drugs (PWID). No such attempt has been made to document the large-scale research evidence on patterns and trends of various substance use patterns in India as yet. The current work is narrative in nature and includes all national surveys on substance use epidemiology in India in the last 2 decades. A few national surveys are conducted in different waves once every few years, including the National Family Health Survey (NFHS) 1 to 5 and the Global Adult Tobacco Survey (GATS) 1 and 2. This review includes data from the waves conducted after 2000 (i.e., NFHS 3,4, and 5 and both GATS 1 and 2).
Overview of the methodology of national surveys on substance use in India
One of the first systematic national surveys on substance use in India was The Extent, Pattern, and Trends of Drug Abuse in India, conducted by Ray et al. in 2004.[7] This study followed the household survey method, including males in the age group of 12 to 60 years. The sample size was 40,697 and prevalence data for alcohol, cannabis, and opiates were reported. The second nationally representative survey on substance use was conducted in 2019 by Ambekar et al.,[8] titled Magnitude of Substance Use in India. This survey included 473,569 individuals aged 10-75 years from all states and Union Territories, followed Household survey and Respondent Driven Sampling techniques, and reported data on Alcohol, cannabis, opioids, inhalants, stimulants, and sedatives.
The burden of tobacco and alcohol use was also included as indicators in other surveys whose primary aims were directed towards understanding mental health, family health, aging, and non-communicable diseases, etc. These surveys included the National Mental Health Survey of India (NMHS), 2015-2016; National Non-Communicable Disease Monitoring Survey (NNCDMS), 2017-2018; National Family Health Survey (NFHS); and Longitudinal Ageing Study in India (LASI), 2020-2021.[9–13] These surveys primarily followed Stratified multistage sampling and household survey designs.
India was also a participant in a few international surveys on the burden of tobacco use among both adult and youth populations, namely, the Global Adult Tobacco Survey (GATS)- 2, 2016-2017 and Global Youth Tobacco Survey (GYTS) -4, 2019.[14,15] The Global Adult Tobacco Survey- 2 followed a Multistage geographically clustered sampling design. The Global Youth Tobacco Survey-4 was conducted among school students and followed a two-stage sample design with schools selected in a probability proportionate to enrollment size.
Details of the methodology of the latest waves of these surveys are provided in Table 1.
Table 1.
Brief methodology of selected national surveys
| Year | Study name | Sample (n) | Sampling method | Substances reported |
|---|---|---|---|---|
| 2004 | The extent, pattern and trends of drug abuse in India (Ray 2004) | 40,697 males (12-60 years) | Household survey | Alcohol Cannabis Opiates |
| 2015-2016 | National Mental Health Survey (NMHS) | 39,532 individuals above 18 years from 12 selected states | Multistage, stratified, random cluster sampling technique with random selection based on probability proportionate to size | Alcohol Tobacco Other substances |
| 2016-2017 | Global Adult Tobacco Survey - 2 (GATS - 2)* | 74,037 individuals aged 15 years or older from 30 states and 2 UT | Household survey Multistage geographically clustered sample design One individual randomly chosen from household | Tobacco |
| 2017-2018 | National Non-Communicable Disease Monitoring Survey (NNCDMC) | 10,659 individuals aged 18-69 years across 27 states | Population based cross-sectional survey Stratified multistage sampling design | Tobacco Alcohol (including HED) |
| 2019 | Magnitude of Substance Use in India (Ambekar et al., 2019) | 473,569 individuals aged 10-75 year from all states and UTs | Household survey+Respondent Driven Sampling | Alcohol, cannabis, opioids, inhalants, stimulants, sedatives |
| 2019 | Global Youth Tobacco Ssurvey - 4 (GYTS - 4)$ | 80,772 school students from 987 schools (aged 13-15 years) from all states/UTs | Two-stage sample design with schools selected with a probability proportionate to enrollment size (Classes- random selection) | Tobacco |
| 2019-2021 | National Family Health Survey - 5 (NFHS-5)# | 636,699 households (724,115 women and 101,839 men) from all states and UTs | Household survey Stratified two-stage sample | Tobacco Alcohol |
| 2020-2021 | Longitudinal Ageing Study in India - Wave 1 (LASI 1) | 72,250 individuals aged 45 and above and their spouses from across 35 states/UTs | Household survey Multistage stratified area probability cluster sampling design | Tobacco Alcohol |
*GATS-1 conducted in 2009-2010. $Previous three rounds of GYTS done in 2003, 2006 and 2009. #Previous four rounds of NFHS done in 1991, 1998-1999, 2005-2006, and 2015-2016
Substance use in the general population
Tobacco use
The extent, patterns, and trends of drug abuse in India did not include tobacco use.[7] However, many national surveys report tobacco use prevalence (both current use and lifetime use), including surveys primarily focused on tobacco use (GATS-1 and GATS-2), tobacco use as a part of mental illness (NMHS 2016), tobacco use as a part of the risk factors of non-communicable diseases (NNCDMS 2018), and various waves of NFHS. Table 2 shows the salient findings related to tobacco use obtained from multiple surveys conducted during the last two decades.
Table 2.
Major findings related to tobacco use from national surveys
| Survey | Major findings |
|---|---|
| NFHS 3 (2005-2006) | Tobacco use: 57.6% (57% in men and 11% in women) |
| • Smokeless tobacco use (chew paan masala/gutkha): 36.3% | |
| • Smoking (cigarette or bidi): 33.4% | |
| GATS-1 (2009-2010) | Current tobacco users: 34.6% |
| • Current tobacco smokers: 14.0% | |
| • Current smokeless tobacco users: 25.9% | |
| Daily tobacco users: 29.1% | |
| • Daily tobacco smokers: 10.7% | |
| • Daily smokeless tobacco users: 21.4% | |
| NMHS (2015-2016) | Tobacco use disorder (moderate and high dependence): 20.9% |
| NFHS 4 (2015-2016) | Tobacco use: 45.5% (45% in men and 7% in women) Most common tobacco use • Paan masala/gutkha chewing: 14.9% |
| • Cigaratte smoking: 13.7% | |
| • Khaini use: 12.4% | |
| GATS-2 (2016-2017) | Current tobacco users: 28.6% |
| • Current tobacco smokers: 10.7% | |
| • Current smokeless tobacco users: 21.4% | |
| Daily tobacco users | |
| • Daily tobacco smokers: 8.6% | |
| • Daily smokeless tobacco users: 18.2% | |
| NNCDMC (2017-2018) | Current tobacco (smoking or smokeless) use: 32.8% (Men: 51.2%, Women: 13.0%) |
| • Current smokeless tobacco use: 24.7% | |
| • Current smoking tobacco use: 12.6% | |
| NFHS 5 | Tobacco use: 40.3% (39% in men; 4% in women) |
| Most common tobacco use | |
| • Chew paan masala/gutkha: 14.2% | |
| • Cigarette smoking: 13.3% | |
| • Khaini use: 12.1% | |
| LASI 1 | Current tobacco use: 30.4% (among 45 years and above*) |
| • Current smoking: 12.2% | |
| • Current smokeless tobacco consumption: 19.8% |
*Includes spouse irrespective of age
In general, tobacco use showed a decreasing trend over the last few years. For example, among men, tobacco use decreased from 45% in NFHS-4 2015-2016 to 39% in NFHS-5 in 2019-2021.[12] Similarly, tobacco use among women dropped from 7% to 4% in the same survey. The findings are also corroborated in separate GATS surveys. For example, there was around a 7% decrease in current tobacco users from GATS-1 in 2009-2010 to GATS-2 in 2016-2017.[16]
GATS-2 reported that almost 38.5% of smokers and 33.2% of smokeless tobacco users made a quit attempt in the past year.[15] Nearly similar findings were reported by NNCDMS 2018, which reported that 35.8% of tobacco users attempted to quit in the past year.[11] Findings on tobacco from various national epidemiological surveys have been summarized in Table 2.
Alcohol use
Current alcohol use
The surveys that specifically focus on alcohol and drug use report data about the current use of alcohol [Table 3]. The current prevalence of alcohol use in the study by Ambekar and colleagues (2019) was reported to be 14.6%.[8] The NNCDMS 2017-2018 conducted during the same time also reported similar current alcohol use (15.9%). Thus, the overall current use of alcohol in India is much lower than the global data provided by the WHO, that estimated nearly 57% of the global population (nearly 3.1 billion people) reported consuming alcohol at least once in past 12 months, with alcohol use disorders affecting nearly 8.6% men and 1.7% women globally.[11,17,18]
Table 3.
Major findings in relation to alcohol use from major national surveys
| Survey | Current alcohol use | Alcohol use disorder/Dependence | Heavy episodic drinking |
|---|---|---|---|
| Ray et al., 2004 | ‘current’ use (during last month): Alcohol: 21% | Dependent 16.8% among current users | |
| NFHS 3 (2005-2006) | Current alcohol use: • Women (15-49 years): 2.2% • Men (15-54 years): 32.0% |
||
| NMHS (2015-2016) | Alcohol Use Disorder: 4.6% (Women: 0.5%, Men: 9.1%) | ||
| NFHS 4 (2015-2016) | Current alcohol use: • Women (15-49 years): 1.2% • Men (15-54 years): 29.5% |
||
| NNCDMS (2017-2018) | Current Alcohol Use: 15.9% • Women: 2.4% • Men: 28.3% |
Heavy episodic drinking: 5.9% (Women: 0.5%; Men: 10.9%) | |
| NFHS 5 (2019-2021) | Currently alcohol use: • Women (>15 years): 1.3% • Men (>15 years): 18.7% |
||
| Ambekar et al., 2019 | Current Users (10-75 years): 14.6% | Alcohol dependence: 2.7% | Heavy episodic drinking: 43% among current users |
| NFHS 5 (2019-2021) | Currently alcohol use: • Women (>15 years): 1.3% • Men (>15 years): 18.7% |
||
| LASI 1 2020 | Among 45 years and above • Infrequent non-heavy drinking: 8.1% • Frequent non-heavy drinking: 2.7% |
Heavy episodic drinking: 2.9% |
The initial survey done by Ray et al.[7] (2004) suggested that the prevalence of current alcohol use (last month) among men was around 21%. However, more recently, Ambekar and colleagues (2019) reported the prevalence of alcohol use among men at about 27.3%. Thus, comparing these surveys on a superficial level suggests that alcohol use among men has increased over the last decade.
On the contrary, NFHS data shows a relatively different story. The prevalence of current use of alcohol among men decreased from 32.0% during NFHS-3 to 29.5% in NFHS-4 and 18.7% in NFHS-5. A recent study reported a significant decline of around 8% and 45% from NFHS-3 to NFHS-4 for the current use of alcohol among men and women.[19] Similar findings were also noted from NFHS-3 to NFHS-5.[20] The decline was statistically significant for almost all the Indian states. However, it is essential to remember that these surveys are methodologically different from the Magnitude of Substance Use in India survey which focuses explicitly on substance use. NFHS has a much broader mandate, and substance use is one small part of the overall data collected. Hence, the findings from the specific surveys about substance use are more likely to be closer to reality.
Alcohol use disorder/dependence
The initial survey conducted by Ray 2004 reported that 16.8% of men (aged 12-60 years) who use alcohol currently are dependent on it. Thus, the overall volume of work reported by the study in relation to alcohol use was around 10.5 million Indians.[8] The NMHS 2016 estimated a prevalence of about 4.6% for alcohol use disorders. Ambekar et al.[8] (2019) estimated the prevalence of around 5.2% of people who use alcohol in a harmful or dependent manner.
Heavy episodic drinking
Heavy episodic drinking has been reported in 3 national surveys. Ambekar et al.[8] (2019) reported that among the current users, almost 43% consume more than four drinks on a single occasion. The rates of heavy episodic drinking in NNCDMS were estimated to be 5.9%.[13] The rates are relatively lower in the population of 45 years and above, as reported by LASI – 1.
Cannabis use
The study of the epidemiology of cannabis is interesting in this context because certain forms of cannabis (like bhang) are licit, while significant others (like charas and ganja) are considered illicit. In the study by Ray et al.[7] (2004), the prevalence of current cannabis use varied with the methodology employed. The National Household Survey reported a prevalence of 3%. However, the study by Ambekar et al.[8] 2019, whose methodology was very similar to the National Household Survey, reported the prevalence of Cannabis use to be 2.8%. This study is also the only study to document the prevalence of licit cannabis (bhang) at 2% and the prevalence of other illicit cannabis use at 1.2% separately [Table 4].
Table 4.
Findings related to Cannabis, opioids and other illicit substances
| Substance | National Survey | Findings |
|---|---|---|
| Cannabis | Ray et al., 2004 | Prevalence of ever use: 3% |
| Ambekar et al., 2019 | Prevalence of current use of cannabis: 2.8% | |
| Bhang use: 2% | ||
| Other illicit cannabis: 1.2% | ||
| Opioids | Ray et al., 2004 | Prevalence of ever use: 0.7% |
| Heroin use: 0.2% | ||
| Ambekar et al., 2019 | Prevalence of current use of opioids: 2.1% | |
| • Heroin use: 1.14% | ||
| • Pharmaceutical opioids: 0.96% | ||
| • Opium use: 0.52% | ||
| Prevalence of harmful opioid use: 0.70% | ||
| Prevalence of opioid dependence: 0.26% | ||
| • Dependence in heroin users: 50% | ||
| • Dependence in opium users: 20% | ||
| Other substances | NMHS, 2015-16 | Weighted prevalence of use of illicit drugs (stimulants, inhalants, and prescription drugs) among adults: 0.6% Weighted prevalence among adult males: 1.1% |
| Ray et al., 2004 | Prevalence of stimulant use (DAMS): 2% | |
| Prevalence of sedative use (RAS): 4% | ||
| Ambekar et al., 2019 | Prevalence of use | |
| • Sedatives: 1.08% | ||
| • Inhalants: 0.7% | ||
| • Cocaine: 0.18% | ||
| • ATS: 0.18% | ||
| • Stimulants: 0.12% | ||
| Prevalence of harmful use and dependence: | ||
| • Sedatives: 0.11% | ||
| • Inhalants: 1.13%, 0.07% | ||
| • Cocaine: 0.03% | ||
| • ATS: 0.06%, 0.02% | ||
| • Stimulants: 0.12% |
Opioid use
Despite the significant burden and public health impact of opioid use in India, nationally representative data on the prevalence and patterns of opioid use remains limited [Table 4]. The study on the extent and patterns of substance use in India by Ray et al.,[7] 2004 employed different methodologies to estimate the prevalence of drug use in India. The Household Survey indicated the prevalence of opioid use as 0.7%, of which 0.2% was specific for heroin use.
Nationally representative data on opioid use patterns and prevalence were provided by the Magnitude survey by Ambekar et al.,[8] 2019, as an update on the 2004 survey. The study combined the Household survey and Respondent Driven Sampling Survey and reported the overall prevalence of current use of opioids as 2.1%. Prevalence was 1.14% for heroin use, 0.96% for pharmaceutical opioids, and 0.52% for opium. Prevalence was 0.70% for the harmful use of opioids and 0.26% for opioid dependence. The survey also reported dependence in 50% of heroin users and 20% of opium users.
Other substance use
Other substances covered in national epidemiological surveys include stimulants, inhalants, sedatives, and hallucinogens [Table 4].[8] The NMHS provided only a weighted prevalence of illicit drugs among adults as 0.6%, which included stimulants, inhalants, and prescription drugs. This prevalence was 1.1% among adult males.[9] The 2004 survey reported the prevalence of use of stimulants as 2% using the Drug Abuse Monitoring System (DAMS) and 4% for sedatives using the Rapid Assessment Survey (RAS) technique.[7]
The 2019 magnitude survey included inhalants, sedatives, cocaine, Amphetamine-type Stimulants (ATS), and hallucinogens. The prevalence reported for inhalant use was 0.7%, 1.08% for sedatives, 0.18% each for cocaine and ATS, and 0.12% for hallucinogens. Prevalence of harmful use and dependence among adults was 0.13% and 0.07%, respectively, for inhalants; 0.06% and 0.02%, respectively, for ATS; 0.11% combined for sedatives, 0.03% combined for cocaine, and 0.03% for stimulants.[8]
Substance use in special populations
Women
Most of the epidemiological studies we reviewed studied the pattern and extent of substance use in females with interest [Table 5]. Ray et al.[7] 2004 conducted thematic interviews to study the impact of substance use on several health, psychological and economic problems. Most studies focused on the pattern of alcohol and tobacco use. The major theme was that the prevalence of alcohol and tobacco use in females was lesser than in males. However, the prevalence of tobacco use ranged from 3-13%, and the most preferred tobacco product amongst females was smokeless tobacco products. The prevalence of current use of alcohol ranged between 0.5-6% across various studies. Comparison of change trends in these studies was difficult due to methodological heterogeneity. Two epidemiological studies (NMHS 2016 & Ambekar et al.[8] 2019) reported the prevalence of other substance use disorders (opioid, cannabis, and cocaine use) and were found to be significantly less amongst females than their male counterparts.[9]
Table 5.
Prevalence of various substance use among women
| Substance | Survey | Indicator | Prevalence in Men | Prevalence in Women |
|---|---|---|---|---|
| Tobacco | NFHS-3 | Current use | 57% | 11% |
| GATS-1 | Current use | 47.9% | 20.3% | |
| Daily use | 40.8% | 16.7% | ||
| Current non user | 52.2% | 79.7% | ||
| NMHS | Tobacco use disorder | 32.8% | 9.8% | |
| NFHS-4 | Current use | 45% | 7% | |
| GATS-2 | Current use | 42.4% | 14.2% | |
| NNCDMC | Current use | 51.2% | 13.0% | |
| Alcohol | NFHS-3 | Current use | 32% | 2.2% |
| NMHS | Alcohol use disorder | 9.1% | 0.5% | |
| NFHS-4 | Current use | 29.5% | 1.2% | |
| NNCDMS | Current use | 28.3% | 2.4% | |
| NFHS-5 | Current use | 18.7% | 1.3% | |
| Ambekar et al., 2019 | Current use | 27.3% (one in 5 dependent) | 1.6% (one in 16 dependent) | |
| Cannabis | Ambekar et al., 2019 | Current use | 5.0% | 0.6% |
| Opioids | Ambekar et al., 2019 | Current use | 4.0% | 0.2% |
| Inhalants | Ambekar et al., 2019 | Current use | 1.34% | 0.07% |
| Cocaine | Ambekar et al., 2019 | Current use | 0.18% | 0.01% |
| Any illicit drug | NMHS | Other substance use disorder | 1.1% | 0.1% |
Children and adolescents
Several global surveys covering India and national epidemiological surveys provide some information about substance use in the adolescent population [Table 6]. Among the worldwide surveys, the GYTSs encompassed adolescents in the age group of 13 to 15 years, and between 2003 to 2019, was conducted in 4 waves. The results indicated an almost consistent decrease in the overall prevalence of tobacco use in both boys and girls. While smokeless tobacco use declined, the prevalence of bidi use increased between 2003 and 2009 and declined in 2019 during the fourth wave of the survey.[14,21,22] In all waves of the study, boys showed a greater prevalence of tobacco use, both smoked and smokeless forms, than girls.[23] The GATS – 1 and 2 also included adolescents and young adults aged 15 to 24 years.[15] Results indicated a decline in the prevalence of smoking and smokeless tobacco forms.
Table 6.
Salient findings from various national surveys in relation to adolescent substance use
| Substance | Age group | Survey | Variable | Prevalence | Prevalence in Boys | Prevalence in girls |
|---|---|---|---|---|---|---|
| Tobacco | 13-15 years | GYTS-1 | Current use | 16.9% | 21.6% | 9.7% |
| Cigarette use | 4.2% | 4.4% | 1.9% | |||
| Bidi use | 2.2% | |||||
| Smokeless tobacco use | 14.0% | |||||
| GYTS-2 | Current use | 13.7% | 14.4% | 8.7% | ||
| Cigarette use | 3.8% | 5.4% | 2.4% | |||
| Bidi use | 4.7% | |||||
| Smokeless | 9.4% | |||||
| tobacco use | ||||||
| GYTS-3 | Current use | 14.6% | 19.0% | 8.3% | ||
| Cigarette use | 4.4% | 8.3% | 1.6% | |||
| Bidi use | 5.3% | |||||
| Smokeless tobacco use | 9.0% | |||||
| GYTS-4 | Current use | 8.5% | 9.6% | 7.4% | ||
| Cigarette use | 2.6% | 3.5% | 1.6% | |||
| Bidi use | 2.1% | |||||
| Smokeless tobacco use | 4.1% | |||||
| 15-24 years | GATS-1 | Current use | 18.4% | |||
| Current smoking | 8.7% | |||||
| Current smokeless | 20.6% | |||||
| Current both use | 5.3% | |||||
| GATS-2 | Current use | 12.4% | ||||
| Current smoking | 1.6% | |||||
| Current smokeless | 9.1% | |||||
| Current both use | 1.8% | |||||
| Up to 19 years | NFHS-3 | Current use | 28.6% | 3.5% | ||
| NFHS-4 | Current use | 18.5% | 1.6% | |||
| Alcohol | Up to 19 years | NFHS-3 | Current use | 11% | 1% | |
| NFHS-4 | Current use | 8.9% | 0.5% | |||
| 10-17 years | Ambekar et al., 2019 | Current use | 1.3% | |||
| Cannabis | 12-18 years | Ray 2004 | Current use | 3% | ||
| 10-19 years | Ambekar et al., 2019 | Current use | 0.9% | |||
| Opioids | 12-18 years | Ray 2004 | Current use | 0.1% | ||
| 10-19 years | Ambekar et al., 2019 | Current use | 1.8% | |||
| Inhalants | 10-19 years | Ambekar et al., 2019 | Current use | 1.17% | ||
| Harmful use | 0.12% | |||||
| Dependence | 0.21% |
Among national epidemiological surveys, tobacco use was included in the NFHS-3 and 4.[24] The results also confirmed the decline in the prevalence of tobacco use, both smoked and smokeless, among the youth population. The NFHS also included the prevalence of alcohol use in youth, with results indicating a decline in the current use of alcohol among both girls and boys over a decade. Alcohol use prevalence among adolescents (aged 10 to 19 years) was also reported in the recent Magnitude survey as 1.3%.[8]
The use of illicit substances among adolescents was reported in the two national epidemiological surveys of 2004 and 2019. The 2004 survey included 8587 adolescents (age group 12-18 years) and reported the prevalence of current use as 3% for cannabis and 0.1% for opioids. The Magnitude survey of 2019 included 82,875 adolescents (age groups 10 to 19 years) and reported the prevalence of current use as 0.9% for cannabis, 1.8% for opioids, and 1.17% for inhalants. The prevalence of harmful use and dependence on inhalants were 0.12% and 0.21%, respectively. While the survey also covered other illicit substances like amphetamine-type stimulants and cocaine, the prevalence of use for adolescents was not provided separately.
Elderly
The elderly population has been conspicuously absent from most of the national epidemiological surveys on substance use in India. Only LASI–1 provided data about tobacco and alcohol use among the elderly (aged 60 years and above). As per the LASI study, around 40.2% of the elderly had never consumed any form of tobacco (either smoking or smokeless), the prevalence of current smoking was 13.8%, while 5.1% of the elderly had discontinued smoking. About 21.3% of participants had used smokeless tobacco but never smoked. Similarly, the estimates for current smokeless use prevalence were 21.5%. Around 3.1% had discontinued using smokeless tobacco. About 15.6% were smokers but never used smokeless tobacco.[13]
Among the 45 years and older population, 86% had never consumed alcohol in any form in their lifetime. Among the rest 14%, 8% were social drinkers, 3% were frequent alcohol drinkers, and another 3% were heavy episodic drinkers. Among 60 years and older, the rates of heavy episodic drinking were estimated to be around 5%. The study indicated a need for greater cognizance of substance use and related issues among the elderly and suggested greater research focus be directed toward substance use in this population.[5,13]
Injecting drug use in India
Drug use by injecting route is a major known risk factor for the HIV epidemic in India. As per the size estimation done under National AIDS Control Program in 2009, the number of People Who Inject Drugs (PWID) in India was just under two lakhs.[25] However, the recent national survey estimated this number to be about 8.5 lakhs. Most PWID prefers one or other opioid drugs (46% heroin, 41% buprenorphine, 4% pentazocine, and 9% sedatives/stimulants/others). Around half of these PWID report reusing, and 1/4th report sharing their injection equipment in the past year.[8] Another recent size estimation exercise reported that there are around 3.9 lakhs PWID in India (accounting for 0.11% of the male population aged 15-49 years).[26]
Strengths of the national epidemiological surveys
The biggest merit of the national surveys included in this review lies in the robust methodology employed to collect data. The sample sizes are enormous and collected using multiple sampling techniques to attain a nationally representative number. People who use substances are generally hard-to-reach population due to poor involvement in community activities and low treatment seeking. Special sampling techniques such as collecting data from key informants, stratified random sampling, respondent-driven sampling, and drug abuse monitoring systems, etc., ensure that data from this hidden population gets captured, providing data from individuals on all severity spectra of substance use. The study instruments are validated using pilot studies and the field staff is provided special training prior to collecting data. The large number of experts involved in these studies ensures quality at every step, from conceptualization to publication. The data thus published is reliable and generalizable and often forms the basis for planning interventions and preventive strategies.
Identified gaps in the available literature
Though many epidemiological studies have been conducted in India, there is little mention of regular monitoring. Though NFHS provides regular data about alcohol and tobacco use, the overall mandate of NFHS is too broad; hence, the data might not be methodologically sound. Also, these surveys do not provide data on other essential variables, such as dependence and heavy episodic drinking. The only exception to this is tobacco, for which GYTS and GATS do the regular monitoring of overall use. However, these surveys fail to capture data regarding tobacco dependence prevalence.
The studies and surveys that have looked for the prevalence and profiles at the household level have not captured the marginalized groups who do not live in traditional housing contexts (e.g., homeless, prison, hospital, or other non-household accommodation). Hence the prevalence rates presented may be lower-bound estimates. However, the national drug use surveys have tried to overcome this limitation by specifically estimating substance use in some of these vulnerable populations. In a similar vein, certain population groups such as the LGBTQIA+ community, migrant population, and commercial sex workers, that are inherently vulnerable to substance use and its adverse consequences have not formed a part of any nationally representative survey yet.
Data regarding certain substances are either not available, or are studied sporadically. One such substance is betel nut which is rampant in the county. The use of newer psychoactive substances is also increasing in many countries across the globe and India. The use of a Newer Psychoactive Substances (NPS) has not been studied systematically in India yet. E-cigarette use is being used worldwide for more than two decades, and vaping is reported to be increasing at alarmingly high rates in many countries. Unfortunately, no data exist for vaping in India. No mechanisms exist for capturing the newer substances’ use either.
The general limitation of recall inherent in retrospective reporting is present in almost all surveys which could lead to potential underestimation of the lifetime prevalence of various substance use disorders. There might also be different social, religious, and legal contexts across many cultures in India that could affect willingness to report substance use hence bound for social desirability bias.
CONCLUSION
This narrative review lays out the findings of various national epidemiological studies reporting substance use in India. Most of these studies followed household surveys and multistage stratified random sampling methods. There is no system for regular monitoring of the prevalence of various substances, and most of these surveys relied on self-reports. Several factors, including recall bias, the stigma associated with substance use, and fear of legal persecution may contribute to the under-reporting of substance use in such surveys.
There is a need to generate nationally representative epidemiological data on substance use among specific population groups including women, adolescents, and the elderly, along with smaller, under-represented vulnerable population groups. These studies also indicate the need to upscale prevention programes and treatment services along with large-scale capacity-building initiatives in order to provide for the enormous burden of disease due to substance use and its related illnesses.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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