Mapping the triple burden of smoking, smokeless tobacco and alcohol consumption among adults in 28,521 communities across 640 districts of India: A sex-stratified multilevel cross-sectional study

National estimates on tobacco and alcohol consumption are insufficient to guide policy at the sub-national level. This study assessed the sex-stratified prevalence of different types of smoking and smokeless tobacco and alcohol consumption among adults aged 15-49 using the National Family Health Survey (2015-16) at sub-national administrative units. Three-level logistic regression models were applied to quantify the variation at districtand community-level in smoking and consumption of smokeless tobacco and alcohol. A higher prevalence of smoking, smokeless tobacco and alcohol consumption was observed among men. The study found that the considerable unexplained variations in two different forms of tobacco and alcohol consumption among men attributed to between-population differences at district-level and community-level. The between-population differences were even larger at the district- and community-level in tobacco and alcohol consumption among women. Continious assessment of tobacco and alcohol consumption at lower administrative units and the development of evidence-based localised cessation interventions must be integrated with health policy to reduce disease burden and preventable deaths.