Abstract
Abstract
Objective
To examine the association between tobacco use and marital living arrangements among married women in Pakistan using data from the 2017–2018 Pakistan Demographic and Health Survey (PDHS).
Design
Cross-sectional secondary analysis of nationally representative survey data.
Setting
The analysis used data from 561 clusters across all regions of Pakistan, collected through a complex stratified sampling design.
Participants
A total of 11,669 married women aged 15–49 years with complete information on tobacco use and living arrangements.
Primary outcome measure
Self-reported current use of any tobacco product.
Results
No significant association was found between marital living arrangement and tobacco use (adjusted prevalence OR (aPOR), 0.969; 95% CI, 0.585 to 1.605). However, higher odds of tobacco use were associated with being illiterate (aPOR, 1.51; 95% CI, 1.05 to 2.16), having more children (aPOR, 1.07; 95% CI, 1.02 to 1.14) and, living in Baluchistan (aPOR, 4.98; 95% CI, 2.20 to 11.26).
Conclusions
Living arrangements were not significantly associated with tobacco use, sociodemographic and reproductive health indicators showed strong associations. Interventions should target illiteracy, reproductive stress and region-specific behaviours.
Keywords: Awareness, Tobacco Use, PUBLIC HEALTH, EPIDEMIOLOGY
STRENGTHS AND LIMITATIONS OF THIS STUDY.
This study uses a nationally representative dataset with a robust sampling design.
This study incorporates complex survey weights to provide population-level estimates.
Self-reported tobacco use may be under-reported due to stigma.
The cross-sectional design precludes causal inference.
Data on spousal smoking and other psychosocial confounders are lacking.
Introduction
Tobacco use remains a significant global public health challenge, accounting for more than 8 million deaths each year, as reported by the WHO. Nicotine, the primary addictive substance in tobacco, fosters dependence and withdrawal symptoms, thereby making cessation difficult for regular users.1 The consequences of tobacco consumption extend beyond individual health, exerting profound physical, psychological, social and economic burdens on both families and healthcare systems.2 3 Despite efforts to reduce tobacco use, prevalence remains a global concern.4 Pakistan ranks among the top 15 countries with the highest burden of disease attributable to tobacco use.1 According to the 2014 Global Adult Tobacco Survey (GATS), 3.9% of women in Pakistan reported tobacco use—a figure likely underestimated due to stigma and under-reporting.5 6 The 2017–2018 Pakistan Demographic and Health Survey (PDHS) reported an even lower prevalence of 2.8% among women aged 15–49 years.2 However, significant variation exists across regions and age groups, with higher rates observed in rural areas and among women aged 35–49 years.2 7 These patterns highlight the importance of considering sociocultural context, gender norms and economic disparities in tobacco research and control efforts.
Although tobacco use has historically been more prevalent among men, the sex gap is narrowing in parts of South and Southeast Asia.8 9 This shift is partially attributed to the increased availability of diverse and affordable tobacco products, as well as evolving social norms.10 11 However, in Pakistan, tobacco use among women remains under-reported and under-researched, partly due to cultural taboos that discourage women from admitting use, especially in conservative and rural communities.7 12 Still, married women may be particularly susceptible because of psychosocial stressors, peer influence, poverty and limited access to healthcare or cessation programmes.13 14
Structural inequalities and gendered expectations within South Asian societies can profoundly shape women’s health behaviours. In Pakistan, as in many culturally conservative countries, social taboos surround the admission of tobacco use, especially by women. In some parts of the country, tobacco use is more acceptable for men than for women. This limits access for potential female consumers.15 However, cultural factors may contribute to tobacco use among married women in Pakistan.16,18 These dynamics are often compounded by caregiving responsibilities, limited autonomy and economic dependence on male partners.13 Consequently, their health choices—such as tobacco use—are influenced not only by personal factors but also by marital and household circumstances.19 In many low- and middle-income countries, including Pakistan, women’s well-being is often closely linked to household structure and the presence of a spouse due to shared financial responsibilities, caregiving roles and emotional support systems. Disruptions in these arrangements—such as prolonged spousal absence—may lead to increased psychological stress, reduced social support and adverse coping mechanisms, including substance use.20 21 A previous study suggested that separation from a partner may increase vulnerability to stress and maladaptive coping behaviours, including substance use.22 However, empirical data examining this relationship among married women in Pakistan remain scarce.
The 2017–2018 PDHS reports that 5.5% of currently married women in Pakistan were living away from their husbands at the time of the survey, with higher rates observed in urban areas.2 Women separated from their spouses may lack social support systems that buffer harmful health behaviours, potentially increasing susceptibility to tobacco dependence.22 Furthermore, married women in deprived regions may face additional risks. Provinces such as Baluchistan and Sindh, which exhibit the highest female tobacco use rates in national surveys, are also characterised by lower indicators of development, including limited access to education, healthcare and employment opportunities.19 Such structural deprivation, combined with cultural normalisation of tobacco use in certain communities, may exacerbate tobacco use among women.20 21
Despite growing awareness, there remains a critical gap in understanding how relational dynamics—such as cohabitation status—interact with sociodemographic and health-related variables to influence tobacco use in women. Unmarried women were excluded from this study to maintain population homogeneity and better assess the unique sociocultural stressors embedded in marital relationships.
This study aimed to investigate the association between tobacco use and marital living arrangements among ever-married women of reproductive age in Pakistan, using nationally representative data from the PDHS 2017–2018.23 It also examines how other socio-economic and reproductive health factors may contribute to tobacco consumption in this population. The findings may inform gender-responsive tobacco control policies and targeted interventions for at-risk women, particularly those living without their partners.
Methods
Study design and data source
This study is a secondary analysis of the PDHS 2017–2018, a nationally representative, cross-sectional survey conducted by the National Institute of Population Studies, with technical support from Monitoring and Evaluation to Assess and Use Results Demographic and Health Surveys (MEASURE DHS). The PDHS employed a multistage, stratified cluster sampling design to collect data on various demographic, health and behavioural indicators, including tobacco use. The survey encompassed all major regions of Pakistan, including Punjab, Sindh, Khyber Pakhtunkhwa, Baluchistan, Islamabad Capital Territory, Gilgit-Baltistan, Azad Jammu, Kashmir and the former Federally Administered Tribal Areas.
Study population and sample selection
The original PDHS sample consisted of ever-married women aged 15–49 years, selected from 16 240 households across 561 clusters. Nineteen clusters were excluded because of security concerns. One eligible woman was randomly selected from each household. For this analysis, women with complete data on marital living arrangements and tobacco use were included. Participants with missing or incomplete responses to these key variables were excluded. The final analysed sample comprised 11 669 ever-married women aged 15–49 years. A flow diagram illustrating the sample selection process is provided in figure 1.
Figure 1. Flowchart for sample selection among ever-married women aged 15–49 years included in the PDHS 2017–2018. PDHS, Pakistan Demographic and Health Survey.
Study variables
Outcome variable: Tobacco use
Tobacco use was defined as the current self-reported use of any tobacco product, including both smoked (eg, cigarettes, hookah and bidis) and smokeless (eg, naswar and chewing tobacco)forms based on PDHS survey items. Participants who reported using any tobacco product at the time of the survey were coded as ‘1’ (tobacco users) and those who did not as ‘0’ (non-users).
Exposure variable: Marital living arrangement
The primary exposure variable was the respondent’s marital living arrangement. Women who were currently living with their husbands were coded as ‘0’ (reference group) and those not living with their husbands (eg, separated, divorced or widowed) as ‘1’.
Multiple sociodemographic and reproductive health variables were adjusted, including age, education level, literacy, urban/rural residence, wealth index, employment status, partner’s occupation, province, history of child mortality, total number of children ever born and visits to health facilities in the past year. These variables were included to control for potential confounding.
The questions used to define key variables, such as tobacco use, marital living arrangement and literacy, were derived from the standardised PDHS 2017–2018 women’s questionnaire. The full survey instrument is available through the DHS Programme website (https://dhsprogram.com) under supporting documentation.
Statistical analysis
All analyses were conducted using STATA version 15.0, applying sampling weights to account for the complex survey design. Descriptive statistics were used to summarise demographic and health characteristics. Bivariate and multivariable binary logistic regression models were employed to examine the association between marital living arrangement and tobacco use. Both crude and adjusted prevalence ORs (aPORs) with 95% CIs were reported. Interaction terms were assessed using a significance level of 0.10, whereas all other statistical tests used a 0.05 threshold for significance. The ORs represent the odds of reporting current tobacco use for each category of the covariate, relative to the reference group. Compared with the reference category, an aPOR >1 indicates higher odds of tobacco use, and an aPOR <1 indicates lower odds.
Results
Of the 20,874 ever-married women surveyed in the PDHS, 9205 participants were excluded because of missing data on key variables, resulting in a final analysed sample of 11,669 women aged 15–49 years. The baseline characteristics of the participants, stratified by tobacco use status, are summarised in table 1.
Table 1. Baseline characteristics of the study sample by frequency of tobacco use (n = 11 669).
| Characteristics | Total n (%) 11 669 (100) |
Tobacco use (yes) N (%) 883 (7.57) |
Tobacco use (no) n (%) 10 786 (92.43) |
|
|---|---|---|---|---|
| Current living situation | Staying with partner (R) | 9861 (84.51) | 816 (92.41) | 9045 (83.86) |
| Staying without partner | 1808 (15.49) | 67 (7.59) | 1741 (16.14) | |
| Region | Punjab | 2476 (21.22) | 91 (10.31) | 2385 (22.11) |
| Sindh | 2103 (18.02) | 316 (35.79) | 1787 (16.57) | |
| KPK | 1954 (16.75) | 55 (6.23) | 1899 (17.61) | |
| Baluchistan | 1316 (11.28) | 300 (33.98) | 1016 (9.42) | |
| Islamabad | 751 (6.44) | 31 (3.51) | 720 (6.68) | |
| Others | 3069 (26.30) | 90 (10.19) | 2979 (27.62) | |
| Type of the place of residence | Urban | 5198 (44.55) | 352 (39.86) | 4846 (44.93) |
| Rural | 6471 (55.45) | 531 (60.14) | 5940 (55.07) | |
| Highest educational level | No education | 5923 (50.76) | 619 (70.10) | 5304 (49.17) |
| Primary | 1568 (13.44) | 92 (10.42) | 1476 (13.68) | |
| Secondary | 2437 (20.88) | 117 (13.25) | 2320 (21.51) | |
| Higher | 1741 (14.92) | 55 (6.23) | 1686 (15.63) | |
| Sex of household head | Male | 10 532 (90.26) | 828 (93.77) | 9704 (89.97) |
| Female | 1137 (9.74) | 55 (6.23) | 1082 (10.03) | |
| Respondent’s current age* | 29.23 (6.05) * | 29.93 (6.372) * | 29.17 (6.021) * | |
| Literacy | Cannot read at all | 6053 (51.88) | 635 (71.91) | 5418 (50.24) |
| Able to read | 5616 (48.13) | 248 (28.09) | 5368 (49.77) | |
| Wealth quintile for urban/rural | Poorest | 3300 (28.28) | 407 (46.09) | 2893 (26.82) |
| Poorer | 2587 (22.17) | 208 (23.56) | 2379 (22.06) | |
| Middle | 2126 (18.22) | 117 (13.25) | 2009 (18.63) | |
| Richer | 1936 (16.59) | 98 (11.10) | 1838 (17.04) | |
| Richest | 1720 (14.74) | 53 (6.00) | 1667 (15.46) | |
| Visited a health facility in the last 12 months | No | 2310 (19.80) | 248 (28.09) | 2062 (19.12) |
| Yes | 9358 (80.20) | 635 (71.91) | 8723 (80.88) | |
| Occupation status | Not working/has not worked in the last 12 months | 10 181 (87.25) | 729 (82.56) | 9452 (87.63) |
| Working | 1488 (12.75) | 154 (17.44) | 1334 (12.37) | |
| Child mortality | No | 10 829 (92.80) | 796 (90.15) | 10 033 (93.02) |
| Yes | 840 (7.20) | 87 (9.85) | 753 (6.98) | |
| Total children ever born | 3.66 (2.18) * | 4.23 (2.462) * | 3.61 (2.155) * | |
| Husband’s occupation | Not working/has not worked in the last 12 months | 454 (3.89) | 37 (4.19) | 417 (3.87) |
| Working | 11 215 (96.11) | 846 (95.81) | 10 369 (96.13) | |
Mean (SD)*.
KPK, Khyber Pakhtunkhwa.
Among the 11 669 women, 883 (7.57%) reported current tobacco use, whereas 10 786 (92.43%) did not. By mean age, tobacco users were slightly older than non-users (29.93 vs 29.17 years). Tobacco use was more prevalent among women with lower socio-economic and educational backgrounds. Specifically, 46.09% of tobacco users belonged to the poorest wealth quintile, and 71.91% reported being illiterate.
Contrary to assumptions about the influence of marital separation, the majority of tobacco users (92.41%) were living with their husbands, and only 7.59% were living apart. Similarly, 60.14% of users resided in rural areas. Regional disparities were notable, with the highest proportion of tobacco users residing in Sindh (35.79%) and Baluchistan (33.98%), compared with lower proportions in other provinces.
Additional characteristics associated with tobacco use included lower educational attainment, residence in male-headed households and higher total fertility rates. Among tobacco users, 9.85% had experienced child mortality, and the average number of children ever born was higher (4.23 vs 3.61). Furthermore, 28.09% of users had not visited a health facility in the past 12 months. Table 1 presents the full distribution of sociodemographic and health-related characteristics by tobacco use status.
To further explore the factors associated with tobacco use, multivariable logistic regression analysis was performed using a complex sample design (table 2). After adjusting for relevant covariates, living apart from the husband was not significantly associated with tobacco use (aPOR, 0.969; 95% CI, 0.585 to 1.605).
Table 2. Crude and adjusted prevalence OR with 95% CI for covariates associated with tobacco use in married women in Karachi, Pakistan.
| Variables | Crude POR with 95% CI | Adjusted POR with 95% CI |
|---|---|---|
| Current living situation | ||
| Staying away from husband | 0.60 (0.36, 0.98) | 0.96 (0.58, 1.60) |
| Staying with husband | Ref | Ref |
| Total children ever born | 1.13 (1.07, 1.19) | 1.07 (1.01, 1.13) |
| Literacy | ||
| Cannot read at all | 2.11 (1.49, 2.99) | 1.51 (1.05, 2.16) |
| Able to read | Ref | Ref |
| Region | ||
| Punjab | 1.13 (0.50, 2.53) | 1.01 (0.45, 2.25) |
| Sindh | 4.21 (1.95, 9.08) | 3.46 (1.61, 7.41) |
| KPK | 0.99 (0.36, 2.68) | 0.78 (0.29, 2.09) |
| Baluchistan | 6.55 (2.92, 14.72) | 4.98 (2.20, 11.26) |
| Islamabad | Ref | Ref |
| Other | 0.20 (0.05, 0.76) | 0.15 (0.03, 0.58) |
KPK, Khyber Pakhtunkhwa; POR, prevalence odds ratio.
However, several factors remained significantly associated with higher odds of tobacco use. Women who had more children (POR, 1.076; 95% CI, 1.017 to 1.138), were illiterate (POR, 1.510; 95% CI, 1.054 to 2.164) or resided in Sindh (POR, 3.461; 95% CI, 1.616 to 7.410) or Baluchistan (POR: 4.986; 95% CI, 2.206 to 11.268) were more likely to report tobacco use.
Table 2 displays both crude OR and aPOR for the predictors included in the analysis. Only variables with significant associations or theoretical relevance are presented; the full model is available on request.
Discussion
This study examined key factors associated with tobacco use among married women of reproductive age in Pakistan using data from PDHS 2017–2018. The primary objective was to investigate the association between women’s living arrangements—specifically, living with or apart from their husbands—and tobacco use. Although this study hypothesised that women living separately from their husbands might be more vulnerable to tobacco use due to social or psychological stressors, the multivariable analysis did not find a statistically significant association between living arrangements and tobacco use.
This non-significant result may reflect the complex social and cultural context of Pakistan, where tobacco use among women remains stigmatised and often concealed within households. Women living with their husbands had a higher absolute prevalence of tobacco use, which may indicate that shared household environments, social norms or exposure to family members who use tobacco contribute more strongly to tobacco consumption behaviours than marital separation alone.24 Cultural restrictions and social modelling may exert a stronger influence on women’s tobacco use than their living status.25 26 Furthermore, the cross-sectional nature of the data limits causal inference, and living arrangement dynamics and tobacco use may influence each other bidirectionally or are affected by other unmeasured factors.
Beyond living arrangements, this study identified several statistically significant factors associated with tobacco use. Notably, women with lower literacy and education levels had 1.51 times higher odds of using tobacco compared with literate women (aPOR, 1.51; 95% CI, 1.05 to 2.16). This finding is consistent with the results of a previous study demonstrating that lower education correlates with increased tobacco consumption, potentially due to reduced awareness of tobacco’s health risks and limited access to cessation resources.9 For instance, the GATS 2012 documented higher tobacco use prevalence among women with lower literacy in low- and middle-income countries, with similar trends reported in Pakistan’s Diabetes Survey and international studies.27 28 These findings reinforce the critical role of educational interventions in tobacco control, particularly in rural and socio-economically disadvantaged settings where knowledge dissemination is limited.
This study also highlighted significant regional disparities in tobacco use. Baluchistan and Sindh exhibited the highest prevalence among married women, aligning with their known status as less developed regions with lower socio-economic indicators, including education and healthcare access.29,31 These disparities may be attributed to several interrelated factors: cultural norms more tolerant of tobacco use, especially among men but potentially influencing women through social modelling and peer pressure, economic hardship and poverty-related stressors that encourage tobacco use as a coping mechanism and the widespread availability and affordability of tobacco products.2 A study showed that households in Baluchistan report high tobacco consumption rates, and residency in similar environments can reinforce behaviours such as tobacco use.32 These regional patterns emphasise the importance of tailored, context-specific tobacco control strategies.
The total number of children a woman has was also associated with tobacco use, with women having more children showing a higher likelihood of consumption. This association might reflect the increased psychosocial stress and responsibilities borne by women with larger families, including caregiving demands and economic pressures.33 Tobacco use could serve as a maladaptive coping strategy for stress relief or momentary escape.34 35 Similar findings from studies in India and Pakistan have linked increased tobacco use among women with higher parity and extended marital duration, suggesting social acceptance may also diminish over time.13 14 36 37 Nevertheless, this relationship is likely to be moderated by education, income and access to support services. Thus, the associations of covariates such as region and literacy must be interpreted with caution, as the model was primarily designed to control confounding for the main exposure (marital living arrangement). Confounding bias may persist for secondary variables due to unmeasured or residual confounders.
Interestingly, contrary to previous reports indicating that older women are more likely to use tobacco in Pakistan, the present study did not find significant associations between age and tobacco use. This could signal a worrying trend of rising tobacco consumption among younger women, possibly fuelled by shifting social norms and the increasing availability of alternative tobacco products.2 7 This finding emphasises the urgent need to broaden public health efforts beyond cigarette smoking to include emerging tobacco forms popular with youth and young women.
Strengths
This study benefits from a large, nationally representative sample from the PDHS, providing robust statistical power and generalisability to married women of reproductive age in Pakistan. The use of multivariable analysis allowed adjustment for potential confounders while investigating multiple relevant factors simultaneously. Additionally, focusing on a rarely studied subgroup—married women—and examining living arrangements contributes novel insights into social determinants of tobacco use in this cultural context.
Limitations
Several limitations should be noted. First, the cross-sectional design limits the ability to infer causality or temporality between tobacco use and associated factors. Second, the use of secondary data restricted the inclusion of certain relevant variables such as tobacco cost, media exposure, mental health status and psychosocial stress, which could influence tobacco use behaviours. Third, tobacco use is likely under-reported due to cultural stigma surrounding female smoking, which could bias prevalence estimates downward. Fourth, the dataset did not include information on tobacco use specifically during pregnancy, which limits our ability to draw conclusions about prenatal exposure risks. Fifth, data on spousal smoking—a key confounder when examining women’s tobacco use in the context of marital living arrangements—was not available in the dataset, limiting our ability to adjust for this important factor. Sixth, the study only included married women aged 15–49 years, limiting generalisability to unmarried women, men and other age groups. Lastly, the data were collected several years ago, and tobacco use patterns may have shifted since then.
Policy implications
The findings suggest an urgent need for targeted policies addressing the socio-economic and educational disparities influencing tobacco use among women in Pakistan. Educational interventions to raise awareness about tobacco harms and improve literacy rates, especially in high-prevalence provinces such as Baluchistan and Sindh, should be prioritised. Tobacco control efforts must also integrate support services addressing psychosocial stress and economic challenges that may drive tobacco consumption as a coping mechanism. Furthermore, regional adaptations of cessation programmes are necessary to address local cultural norms and accessibility barriers. Broader regulation and monitoring of alternative tobacco products are also crucial to prevent uptake among young women.
Future directions
Future research should aim to employ longitudinal designs to clarify causal relationships between tobacco use and associated factors. Expanding study populations to include unmarried women, men and broader age groups will improve generalisability. Innovative, culturally sensitive data collection methods may reduce stigma-related under-reporting. Qualitative studies exploring the motivations behind tobacco use can provide valuable insights for intervention design. Finally, public health programmes should continuously adapt to emerging tobacco products and changing social norms to effectively combat tobacco use in diverse populations.
Conclusion
In this study, a substantial portion of married women in Pakistan use tobacco, influenced more by social, educational and regional factors than by living arrangements. Lower literacy, residing in less developed provinces such as Baluchistan and Sindh and having more children were significantly associated with increased tobacco use. These findings highlight the need for targeted, culturally sensitive public health interventions that address educational disparities, regional socio-economic inequalities and psychosocial stressors contributing to tobacco use among women. Policymakers should prioritise tobacco control programmes that include educational campaigns, mental health support and regional adaptations to curb tobacco use and improve health outcomes for women and their families.
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepublication history for this paper is available online. To view these files, please visit the journal online (https://doi.org/10.1136/bmjopen-2025-099643).
Data availability free text: The dataset analyzed during the current study is publicly available and can be accessed from https://www.dhsprogram.com/data/available-datasets.cfm?ctryid=31. This dataset was accessed in compliance with the repository’s terms of use, and no special permissions were required for this secondary analysis.
Patient consent for publication: Not applicable.
Ethics approval: This study involved secondary data analysis, and no direct human participant involvement occurred. As such, ethical approval for the analysis of this data was obtained from the Ethics Review Board, Aga Khan University, Pakistan, which reviewed and approved the use of de-identified data. Since the data used were previously collected and anonymised, specific consent to participate was not required from the study participants. However, consent was obtained by the original study team during the initial data collection process, adhering to all ethical standards and guidelines at that time.
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Data availability statement
Data are available in a public, open access repository.
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