Tobacco epidemic in India : Are we doing enough ?

Dr Dhaneshwor Naorem *

Every year, 31st May is observed as 'World No Tobacco Day,' highlighting the health risks associated with tobacco use, and advocating for effective policies to reduce tobacco consumption. This year's theme is "Commit to Quit"- promulgated to provide people the tools and resources they need to successfully quit tobacco.

As per World Health Organization (WHO) estimate, tobacco causes around 6 million deaths every year making it the biggest preventable death world over. With more than 270 million tobacco consumers in India, it becomes imperative to address this health hazard and stir up strong measures toward damage control.

Patterns and prevalence of Tobacco use in India

Global Adult Tobacco Survey (GATS) reports that 28.6% of adults in India consume tobacco in some form or the other. Among them, 75% use smokeless tobacco (eg. Khaini, Gutka, Pan Jarda), 35% smoke (cigarette & beedi), and 11% consume both. Nearly one in two (42%) male and one in seven (14%) female use tobacco in some form. Unlike western countries where cigarette smoking is almost the only form of tobacco use, 2/3rd of users in India prefer smokeless tobacco.

The prevalence of tobacco use among all the States and Union Territories ranges from the highest of 64.5% in Tripura to the lowest of 10% in Goa. Manipur with 55% of its adult population using tobacco, ranks third in the list. All the top five States on the list are in North East India.

Two in every five daily tobacco users had started using tobacco before attaining the age of 18. The Global Youth Tobacco Survey (GYTS) reported 14.6% of school-going children (aged 13-15 years) in India were using tobacco, and Nagaland had the highest percentage (63%) of tobacco users among this vulnerable group.

Health consequences from tobacco use

Tobacco consumption virtually affects every organ of the human body. Broadly, tobacco-related health hazards can be grouped as a) Cardiovascular diseases (Heart diseases, stroke), b) Lung diseases, and c) Cancer.

According to WHO, tobacco kills more than 10 lakh people each year in India, accounting for 9.5% of all deaths. Cardiovascular diseases which are responsible for 48% of these deaths are the commonest cause of tobacco-related mortality. As the second-largest tobacco-using population, India accounts for 83% of the world's heart disease burden, despite having less than 20% of the world's population.

More than 80% of chronic lung diseases are attributed to smoking. Passive smoking also causes respiratory infections, poor lung compliance, chronic obstructive pulmonary disease (COPD), and asthma worsening.

Cancer is another serious health issue that has its roots deeply entrenched in tobacco usage. Evidence from the population-based registry in India has shown that more than 50% of cancers are related to tobacco consumption. The prevalent habits of chewing tobacco and smoking make cancers of the oral cavity, lung, pharynx, and esophagus the commonly encountered cancers in India.

Tobacco has been found responsible for 90% of oral cancers, and it's noteworthy to mention that India has the highest oral cancer rates in the world. Within India, the North Eastern States have the highest prevalence of these cancers.

Tobacco consumption also adversely affects the digestive process, vision, bone metabolism, and dental hygiene. In addition to other health risks as men, women also experience an increased risk of infertility, pregnancy complications, premature births, low birth weight infants, and stillbirths. Second hand smoke exposure in children also leads to ear and respiratory infections, sudden death, and severe asthma.

A quarter of tobacco-related death are children who have been exposed to passive smoking. In the context of the ongoing COVID-19 pandemic, smokers suffer from reduced lung capacity which greatly increases the risk of serious illness due to COVID-19.

Further, smokeless tobacco users tend to spit in public places and therefore, increase health risks especially those of spreading infectious and contagious diseases including COVID-19. The large gathering at the retail outlets where smokeless tobacco products are sold also poses the risk of disease spread.

Economic and Social Burden

A popular notion upheld by the tobacco industry is-"economy needs tobacco." This argument is about industry generating revenue for farmers and workers in tobacco factories, distributors, vendors, and advertising agencies, as well as profits for the Government from exports and taxes.

Tobacco contributes to the extent of Rs 8500 crore to the Indian economy annually. Whereelse, the estimated annual health expenditure on the 3 major tobacco-related diseases, namely cancer, coronary artery disease, and COPD, is around Rs 31,000 crore. This far exceeds the Government-generated revenue from tobacco.

Furthermore, the Government expenditure on health, in general, constitutes just 18% of the total cost, and the remaining 82% is directly from a patient's pocket. Expenses incurred in tobacco use substitute the basic needs of food and education. Thus, the consumers and their families have always remained at the receiving end of this social evil.

Tobacco Control and Challenges in India

Tobacco control initiatives can be broadly perceived as 3 areas of focus: i) Measures to curb production and sales by the industry, ii) Public health awareness, and iii) Promoting tobacco cessation.

The Union Government has taken various measures to this effect:
1) Enactment of the "Cigarette and other Tobacco Product (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act- (COTPA) 2003"

2) Ratification of WHO Framework Convention on Tobacco Control (FCTC). India has been elected coordinator of the countries of the WHO Southeast Asia Region.

3) Government of India has issued regulations under the Food Safety and Standards Act - 2006 which lay down that tobacco or nicotine cannot be used as ingredients in food products. The manufacturing and sale of certain smokeless tobacco products have been prohibited under this regulation.

4) Ministry of Health and Family Welfare, Government of India, launched National Tobacco Control Programme (NTCP) in 2008, with the objective to a) Create awareness about tobacco-related diseases b) Reduce production & supply of tobacco products, c) Ensure effective implementation of anti-tobacco laws, and d) Help people in quitting tobacco use through 'Tobacco cessation Centres'.

5) A pilot project for 'developing alternative cropping systems to replace beedi and chewing tobacco' was initiated by the Ministry of Health and Family Welfare along with Central Tobacco Research Institute (CTRI), Rajahmundry in 2008. Ministry of Labour launched another pilot program for skill-based vocational training of beedi workers with a vision to provide an alternative livelihood.

Tobacco control in India is complex and plagued with multiple challenges. Global Adult Tobacco Survey (GATS)-2 in 2016-17, compared to its previous survey (2010), revealed a 6% decrease in tobacco consumption in the country. The decrease however remained non-uniform. Sikkim, with compliance of >95% of targeted parameters, was declared the first smoke-free State in the country. Despite all anti-tobacco measures, its prevalence increased in the rest of the North Eastern states, the most prominent being a 10% increase of tobacco users in Assam.

The survey also revealed a wide disconnect between 'Health-related awareness' and 'Desired behavioral change' in society. Across all States and Union Territories, Mizoram had the highest (98%) awareness regarding tobacco-caused health problems. The bitter irony is that Mizoram with 60% of its adults using tobacco, ranked 2nd highest in the country.

GATS-2 reported nearly half (45%) of the users had planned to quit tobacco, but only 5.3 % of them succeeded in doing so. Presently, India has 19 tobacco cessation clinics (TCCs), which undoubtedly is an inadequate effort considering its near 270 million tobacco-consuming population. A vast majority of its population lives in a rural habitat and has limited access to these cessation centers.

Following stringent anti-tobacco laws passed against the direct advertisement of products (COTPA, 2003), several tobacco companies have resorted to alternative strategies which include brand stretching, surrogate advertisement, and corporate sponsorship.

Measures are required to plug these loopholes for effective implementation. Regarding the bans on gutkha and loose cigarette sales, ‘Laws in the book’ hardly translate into ‘laws on the streets’ in countries like India where regulatory enforcement is weak. Taxation, a powerful tool to curb tobacco usage, remained relatively non-effective as 90% of total tobacco excise revenue comes from cigarettes, which forms only 11% of the entire tobacco consumption in India.

This unequal distribution in taxation on tobacco products highlights an unenthusiastic stand to curtail the evils.

The way forward: Appropriate implementation of tobacco control policies is the biggest challenge the country is facing today. The establishment of comprehensive implementation and regulatory structure at the National and State level is the need of the hour. There should be targeted programs addressing different user groups with a special focus on vulnerable groups such as females, youth, and children.

The very fact that nearly half (45%) of the users had planned to quit tobacco should be seen as a ‘window of opportunity and road-maps to assist them to prioritize. A majority (75%) of the Indian population is rural and people have limited access to health care, tobacco control strategies need to be mainstreamed with other National health programs, within the overall framework of the NRHM.

Sustained effort involving various stakeholder ministries and departments, which includes but is not limited to, Human Resource Development, Finance, Agriculture, Labour, Commerce, RD , IPR, along with the Ministry of Health & Family Welfare, will for sure ensure better penetration of policies.