|TOBACCO AND HEALTH
|Year : 2010 | Volume
| Issue : 5 | Page : 3-8
Tobacco and health in India
V Rao1, P Chaturvedi2
1 Department of Head and Neck Surgery, Kidwai Memorial Institute of Oncology, Dr M.H Marigowda Road, Bangalore 560 029, India
2 Associate Professor and Assistant Surgeon, Department of Head and Neck Surgery, Tata Memorial Hospital, Dr Ernest Borges Road, Parel, Mumbai- 400 012, India
|Date of Web Publication||9-Jul-2010|
Department of Head and Neck Surgery, Kidwai Memorial Institute of Oncology, Dr M.H Marigowda Road, Bangalore 560 029
Source of Support: None, Conflict of Interest: None
Tobacco is a well-acknowledged social and health evil. The history of tobacco use traces back to the dawn of human civilization and has been deeply entrenched into the human society since time immemorial. The social, economic, and health impact of tobacco has been a subject of intense debate over the recent decades. For India, this problem has been a unique one, with the consumption patterns either largely influenced by the socioeconomic backgrounds or dictated by the cultural diversity. With more than 200 million tobacco consumers in the country at present, it becomes imperative to address this health hazard and stir up strong measures toward damage control. This article addresses the tobacco problem, its evolution, and the factors that have affected the growth of Indian tobacco industry. It also highlights the current legislative measures against tobacco, fiscal gains to the government, and the serious health and economic impact to the consumer, compounded by the increasing cost of private health care in the present era of consumerism.
Keywords: India, tobacco, health
|How to cite this article:|
Rao V, Chaturvedi P. Tobacco and health in India. Indian J Cancer 2010;47, Suppl S1:3-8
Publication of the supplement was supported by the funds from the 14th World Conference on Tobacco or Health, March 8-12, 2009, Mumbai. The Guest Editors, Editors, Authors and others involved with the journal did not get any financial or non-financial benefit from the sponsors.
| » Brief history of tobacco|| |
The history of tobacco is entrenched into the human civilization almost since its origin and dates back to a few thousand years. This agricultural product was then perceived with a mythical notion and predominantly used as an entheogen (substance that causes one to experience feelings of inspiration, often in a "spiritual" manner) by the Native Americans.
It then slowly attained its popularity as a recreational herb and soon spread to the European nations fostering economic growth. Tobacco gained entry into the royal courts of India as a barter commodity to trade Indian textiles by the Portuguese in the 17th century. The British East India Company further glorified tobacco as a cash crop and promoted its production for domestic usage and foreign trade.  With increasing demand for tobacco in India, the Imperial Tobacco Company, now the Indian Tobacco Company (ITC) Limited was established in India in 1910, nearly a decade after its inception in 1901, following the amalgamation of 13 tobacco companies. A few decades later, the beedi industry gained entrenchment into the tobacco arena. The low unit value of beedi made it a popular product among the working class, and its usage soon surpassed cigarette usage in the country. Interestingly, chewing tobacco, the popular form of smokeless tobacco, also traces its origin to the agricultural population of Native Americans. Historically, it was one of the most common forms of tobacco consumed, until recently when it was overtaken by cigarettes in the early 20th century. Presently, its usage is restricted to the rural population of the western world. On the other hand, the chewing tobacco industry has grown to become the most popular form of tobacco consumed in India. Thus, the history of tobacco brings into light a web of economic, cultural, and political intrigue.
This increasing popularity of tobacco continued to grow until the mid-1990s when it was condemned as a health hazard, following scientific revelations.
| » Prevalence|| |
The use of tobacco in India has witnessed varied patterns, which include smoking, chewing, applying, sucking, gargling, and so on. Each of these patterns of consumption is governed by the geographic area, economic status, sociocultural, and religious influences. The wide range of tobacco products thus made available are either industrially manufactured on a large scale or made locally in small scale industries, and sometimes by vendors or consumers themselves (such as dhumtis). 
Presently, India has more than 200 million tobacco consumers; only 13% of them consume it in the form of cigarettes, whereas 54% consume it in the form of beedis and the rest in raw/gutka forms.  Worldwide, 85% of the tobacco cultivated is used in the production of cigarettes. Hence, the tobacco consumption pattern in India markedly differs from the rest of the world in terms of product configuration. 
A recently conducted national cross-sectional household survey found the highest prevalence of tobacco use in South Bihar (94.7%), followed by Uttar Pradesh (87.3%), and high rates in the northeastern states. The lowest rates were found in Kerala (20.6%).  The National Household Survey of Drug and Alcohol Abuse conducted in 25 states (excluding Jammu and Kashmir) in 2002 reports that 55.8% of males aged between 12 and 60 years currently use tobacco.  The prevalence of tobacco use among males is higher compared with females and among older age groups compared with the younger age groups. The prevalence of tobacco consumption was found to be 2.4% for
women smokers and 12% for women consuming chewing tobacco.  Smoking among women in most high-income countries has increased over the past 20 years, although there has been a fall in smoking among men over the same period.  The Global Youth Tobacco Survey (GYTS) reveals that among 13-15-year-old school-going children, the current use of any tobacco product varies from 3.3% in Goa to 62.8% in Nagaland. 
Over the years, India's position has risen from the third-largest to the second-largest unmanufactured tobacco consuming country in the world. This suggests that compared with cigarettes, more of the other forms of tobacco are consumed in India and that this trend is increasing in recent years. The recent years have thus witnessed the tobacco industry mushrooming unabated with increasing numbers falling prey to the "demerit good."
| » Health consequences from tobacco use|| |
Globally, tobacco is responsible for the death of 1 in 10 adults (about 5 million deaths each year) with 2.41 (1.80-3.15) million deaths in the developing countries and 2.43 (2.13-2.78) million in the developed countries. , A recent nationwide study on smoking and mortality in India estimated that cigarette and beedi smoking causes about 5% of all deaths in women and 20% of all deaths in men aged 30-69 years, totaling to 1 million deaths per year in
India.  Health consequences arising from tobacco consumption virtually affect every organ of the human body leading to ill health, morbidity, and mortality. Broadly, the key health hazards commonly causing morbidity and mortality can be perceived under 3 groups, namely, cardiovascular diseases (CVDs), pulmonary diseases, and cancer.
CVD is one of the world's leading causes of death and far outweighs the deaths from cancer. A large proportion of these deaths are related to tobacco consumption. It is estimated that by 2020, CVD will be responsible for around 50 lakh deaths (about 40% of the total deaths) in the country.  More than 80% of the chronic lung diseases are attributed to smoking and would account for about 8 lakh deaths (6%) by 2020. Tuberculosis deserves a special mention among the infections affecting the respiratory system. Tuberculosis is responsible for 1/3 of the deaths related to smoking, with half the deaths occurring within the fifth decade.  Added to this, the effects of passive smoking include respiratory infections, poor lung compliance, chronic obstructive pulmonary disease (COPD), and worsening of asthma.
Cancer is another serious health condition that has its roots deeply entrenched in tobacco usage. Evidence from the population-based registry in India has shown that more than 50% of the 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 consumption also adversely affects reproductive health, digestive process, vision, bone metabolism, dental hygiene, and perhaps, diminished performance in virtually every functioning cell. Additional intangible losses arising from this "demerit good" are emotional burden to family, school dropout due to child labor used for tobacco cultivation, and most of all the pain and suffering evoked by dreadful diseases.
| » Economics of tobacco|| |
The discussion on economics of tobacco can be broadly professed into economics related to the industry, the government, and the consumer.
India is one of the biggest tobacco markets in the world, ranking third in total tobacco consumption behind only the markets of China and the United States. A popular notion upheld by the tobacco industry is-"economy needs tobacco." This argument pertains to industry supporting revenue generation for farmers and workers in the tobacco factories, distributors, vendors, and advertising agencies, and profits to government from exports and taxes. It is estimated from the Annual Survey of Industries (ASI) data that almost 85% of employees of tobacco manufacturing industries are employed in the beedi industry. Export of tobacco is an important source of revenue with a quantity of 1,28,460 M, generating a revenue of 2173 crore rupees for the year 2009. A major part of this revenue comes from the export of unmanufactured tobacco (as high as 85%).
Of the 4 major manufacturers of cigarettes in India, the ITC Limited, Godfrey Phillips India (GPI) Limited, Vazir Sultan Tobacco (VST) Industries Limited, and the Golden Tobacco Company (GTC) Limited, the ITC Limited alone accounts for more than 60% of the total production and 80% of the sales and market share. 
The annual turnover of the leading tobacco companies, such as ITC and Godfrey Phillips presently exceeds Rs 2000 crores (>$450 million).
The overall trend of total manufactured tobacco production showed a steady increase from Rs. 4237.7 million in 1973-1974 to Rs 80,319.6 million in 1997-1998. 
| » Government-fiscal gains from tobacco|| |
In 2000-2001, the contribution of tobacco to the Indian economy was to the extent of Rs 81,820 million, which accounted for about 12% of the total excise collections. From 1951 to 2001, there was an increase in the production by 130%, in excise revenue by 31,614%, in export revenue by 5823%, and in consumption by 92%. Tobacco contributes about 4% to the India's agricultural exports.
Contribution of tobacco to GDP from excise revenues to corporate taxes is often upheld as an argument against tobacco control. Since the 1980s, the government has abolished the levy on leaf tobacco with a shift in burden to the finished products. Tobacco excise is an important source of revenue for the national budget.
Although beedi, chewing tobacco, and smokeless tobacco, account for 81% of the national consumer market, they comprise only 12% of the total tobacco excise collected from tobacco products.  Cigarettes account for a major part of the revenue generated from excise.
| » Consumerism and tobacco|| |
Cancer, coronary artery disease, and COPD have been the deadly trio implicated with mortality and morbidity associated with tobacco. Rath and Chaudhary, in a report by the Indian Council of Medical Research task force elaborated the expenditures incurred relating to the 3 health issues, namely, CVD, pulmonary diseases, and cancer. , The average cost to treat patients of tobacco-related cancers was estimated to be Rs 3,50,000/- per head (at 1999 level). These costs included the expenditure that arises from direct treatment expenditure to the patient, to the institution, absenteeism, and loss of pay due to premature death. Similar cost estimates derived for COPD and CAD were Rs 29,000/- and Rs 23,300/-, respectively. Taking the above figures into consideration and with the present trends in tobacco consumption in India, an average total loss of 277.611 billion rupees was estimated for the year 1999. These figures quoted pertain to treatment received at institutional setting and cost estimates over the last decade. Reddy and Gupta updated these costs for 2002-2003, estimating the total cost for the 3 major tobacco-related diseases to be Rs. 308.33 ($6.6) billion.  This amount far exceeds the government-generated revenue from tobacco and is almost 1/4 of India's expenditure on health ($25 billion).  An issue largely unaddressed in this study was the cost burden to passive smokers, which would further add to the existing health burden.
This amounts to serious economic losses, especially when 75% of the Indian population lives on less than $2 a day (purchasing power parity [PPP]).  This is significant, especially in a country where the government expenditure on health as a part of the total government expenditure constitutes only 3.4%.  Furthermore, the government expenditure on health in general constitutes just 18% and the remaining 82% is private expenditure. 
Thus, confinement due to illness owing to tobacco consumption in this vulnerable population further increases the health burden and abates the economic growth of the nation.  Thus, the see-saw effect of tobacco economics is obvious with the consumer at the receiving end.
| » History of tobacco control, legislation, and litigation|| |
Since the first report linking tobacco to cancer, the last 5 decades have witnessed major strides in the tobacco control measures. Tobacco control initiatives can be broadly perceived as 3 areas of focus: measures to curb production and sales by the industry, public health awareness, and promoting tobacco cessation.
Measures to curb the industry:
Taxation on tobacco products is another powerful tool to curb tobacco usage. However, the present trends on taxation show that almost 90% of total tobacco excise revenue in India comes from cigarettes, which interestingly forms only 15% or less of the entire tobacco consumption in India. This unequal distribution in taxation on tobacco products clearly depicts an unenthusiastic stand to curtail the larger evils. In addition, a part of this revenue goes into research for higher yields of tobacco. Hence, taxation on tobacco could represent a potential trail leading to a tobacco-free nation.
- With growing evidence on the hazards of tobacco consumption, various legislations and comprehensive tobacco control measures have been enacted by the government of India as a key initiative to curb the tobacco industry. These have been enumerated in the followingCigarette Act (Regulation of Production, Supply, and Distribution), 1975-"Cigarettes smoking is injurious to health," was to be displayed on all packets and cartons of cigarettes and cigarette advertisements.
- Prevention of Food Adulteration Act (Amendment), 1990-similar statutory warning for chewing tobacco and pan masala.
- In 1990, through an Executive Order, the Union Government prohibited smoking in all health care establishments, government offices, educational institutions, air-conditioned railway cars, chair cars, buses, suburban trains, etc.
- The Drugs and Cosmetics Act, 1940 (Amendment), 1992, bans tobacco in dental care products.
- The Cable Television Networks (Amendment) Act, 2000, prohibits tobacco advertising in state-controlled electronic media and publications and on cable television.
- The Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA).
- In 2008, Section 4 of the COTPA specifying the smokefree rules came into effect, prohibiting smoking in all public and work places from October 2, 2008. As a result, public places, such as offices, airports, hospitals, shopping malls, cinema halls, banks, hotels, restaurants and bars, public transports, educational institutions, and libraries are now smokefree across India.
- Alternative cropping: In 2008, the Ministry of Health and Family Welfare initiated a pilot project for developing alternative cropping systems to replace beedi and chewing tobacco with Central Tobacco Research Institute (CTRI), Rajahmundry.
- Alternative livelihoods: The Ministry of Labour has launched a pilot program for skill-based vocational training of beedi workers across various states in India.
Following stringent laws passed against direct advertisement for tobacco products (COTPA, 2003), several tobacco companies have resorted to alternative strategies. These strategies include tactics from brand stretching, surrogate advertisement to corporate sponsorship [Figure 1],[Figure 2],[Figure 3]. Products bearing the name of the original tobacco products (such as Wills, Manikchand) are being utilized for brand promotions, thus flouting the existing laws.
India has played an active leadership role in the global fight against tobacco. The Advocacy Forum for Tobacco Control (AFTC), a national alliance against tobacco, provided opportunity for all key tobacco control advocates to join an effective campaign for tobacco control resulting in the modified and comprehensive Tobacco Control Bill that was passed in 2004. Although several legislations have been passed by the government to curb tobacco use, effective implementation and enforcement of these laws are yet to be strongly implemented. Towards this effect, the Ministry of Health and Family Welfare (MOFHW) has released a resource manual that deals with the essential aspects of tobacco control laws and outlines the legal arrangement in India for tobacco control. These manuals also present situational analysis of enforcements and make recommendations to improve enforcement and implementation of tobacco control laws.
| » Public health awareness|| |
Pictorial display on cigarette and beedi packs carries a photograph of an X-ray plate of the chest of a man affected by cancer (understanding the significance of these pictures may require a radiologist). Packets of chewing and smokeless tobacco products carry just a simple image of a scorpion, depicting cancer!
The National tobacco control cell has developed several antitobacco television advertisements and the Ministry of Health had launched a health program (Kalyani) on the regional channels of Doordarshan for half an hour a week. However, the airing of these advertisements has been very infrequent with spurts seen during the World No Tobacco Day.
It is evident from the above description that these measures are sure to be far from educating the masses. Especially, in a country where a majority of the population resides in rural areas, emphasis needs to be laid on mass education with adequate media utilization.
| » Promoting tobacco cessation|| |
Presently, India has about 18 tobacco cessation clinics (TCCs) across the country. This clearly is an inadequate effort taking the existing 250 million tobacco consuming population into consideration. In addition, a vast majority of the population lives in a rural habitat and have limited access to cessation centers.
As high as 75% of the Indian population is rural and people have limited access to health care and travelling to a cessation clinic far away may not be practicable.
Since the year 2002, 34,741 cases were registered across the 18 TCC in India. 92% of those registered in the TCCs were men, and 8% were women. This clearly shows the sociocultural influences compounded by economic set back that prevents adequate utilization of these services.
| » WHO Frame work convention for tobacco control|| |
The World Health Assembly adopted the Framework Convention on Tobacco Control (FCTC) at its 56th Session in May 2003. India was the eighth country to ratify the convention on 5 February 2004. Although the FCTC does not lay down laws against tobacco advocacy, it sets guidelines for various national and international measures that would aid tobacco control. India has been unanimously elected as the coordinator of the countries belonging to the WHO South-East Asian Region. The FCTC is the first ever international public health treaty of any kind. 
| » Tobacco control researches|| |
Research on tobacco control has shown growing enthusiasm in the recent years with several antitobacco advocacy groups and government organizations emerging as research partners. The Research of International Tobacco Control (RITC) and the WHO has played a lead role to identify several key issues pertaining to tobacco control. These initiatives have paved the way to promote research in a qualitative and quantitative manner. Although the socioeconomic factors influencing the high income nations are well studied, the same is not true for the developing nations where a majority of the tobacco consuming population thrives. Tobacco control research in India has identified the niche areas based on the population in question, patterns of tobacco production and consumption, judicial scenario, and the prevalent health care systems.
The National Sample Surveys (NSS) and the National Family Health Surveys (NFHS) have given an insight into the practice and patterns of tobacco consumption in India. The 10-year follow-up study conducted by Gupta et al in Ernakulam demonstrated the increased risk of death among the tobacco consumers.  Rath and Chaudhary,  John et al, and several others have examined the economic and health burden arising from tobacco consumption in India elaborating the various tobacco-related diseases and the resulting mortality. Similar case controlled studies conducted in India have proven the causal role of tobacco in various cancers. Research on program intervention, especially at the school and college level is also being conducted further adding to the tobacco research armamentarium. Thus, evidence-based research has not only given a deep insight into the prevailing problems but also paved newer roads to initiate strong measures to curb tobacco use in India.
| » Future|| |
As it may be evident from the current scenario, the need of the hour is to integrate and strengthen our efforts toward enforcement of legislation, public health awareness, and promoting TCCs. The prevalent pattern of tobacco consumption and socioeconomic diversity clearly indicates a need to advocate more stringent antitobacco norms, and to reinforce our efforts toward the rural and semi-urban population.
Increase in the taxation across the range of tobacco products can prove to be a significant intervention for tobacco control. Utilization of mass media for antitobacco advocacy has been largely inadequate. Considering its enormous viewership and mass appeal, the media, such as Doordarshan, have the potential to reach out to masses and propagate antitobacco legislative and health awareness. Steps to rehabilitate tobacco farmers with alternative crops, and establishing TCCs in peripheral health centres, district hospitals, and local health care centres by the government would go a long way in furthering its commitment toward tobacco control.
| » References|| |
|1.||Reddy SK, Gupta PC. Report on tobacco control in India. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2004. |
|2.||Indian Institute of Foreign Trade (IIFT). Medium term plan for tobacco exports from India and strategies for the next five years. New Delhi: IIFT; 2002. |
|3.||Rani M, Bonu S, Jha P, Nguyen SN, Jamjoum L. Tobacco use in India: Prevalence and predictors of smoking and chewing in a national cross sectional household survey. Tob Control 2003;12:e4. [PUBMED] [FULLTEXT] |
|4.||Srivastava A, Pal H, Dwivedi SN, Pandey A, Pande JN. National Household Survey of drug and alcohol abuse in India (NHSDAA). New Delhi: Report accepted by the Ministry of Social Justice and Empowerment, Government of India and UN Office for Drug and Crime, Regional Office of South Asia; 2004. |
|5.||Tobacco control in developing countries. In: Jha P, Chaloupka F editors. Oxford: Oxford University Press; 2000 .p. |
|6.||Global Youth Tabacco Survey Collaborative Group. Tobacco use among youth: A cross country comparison. Tob Control 2002;11:252-70. [PUBMED] [FULLTEXT] |
|7.||Tobacco Free Initiative. Why is tobacco a public health priority? Geneva: World Health Organization; 2004. Available from: http://www.who.int/tobacco/health_priority/en/index.html . [accessed on 2010 Jan 18]. |
|8.||Ezzati M, Lopez AD. Estimates of global mortality attributable to smoking in 2000. Lancet 2003;362:847-52. [PUBMED] [FULLTEXT] |
|9.||Jha P, Jacob B, Gajalakshmi V, Gupta PC, Dhingra N, Kumar R, et al. A nationally representative case-control study of smoking and death in India. N Engl J Med 2008;358:1137-47. [PUBMED] |
|10.||Murray CJL, Lopez AD. Global burden of disease. Global burden of disease and injury series. Vol. 1. Boston: Harvard School of Public Health; 1996. p. |
|11.||Gajalakshmi V, Peto R, Kanak TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India: Retrospective study of 43000 adult male deaths and 35000 controls. Lancet 2003;362:507-15. |
|12.||Centre for Monitoring Indian Economy (CMIE) Prowess (Release 2) database; 2004. |
|13.||Annual Survey of Industries, 1997-98, Central Statistical Organization, New Delhi. |
|14.||Indira Gandhi Institute of Development Research (IGIDR). Opportunities and challenges in tobacco. Mumbai; 2002. |
|15.||Rath GK, Chaudhary K. Estimation of cost of management of tobacco-related cancers. Report of an ICMR Task Force Study (1990.1996). New Delhi: Institute of Rotary Cancer Hospital, All India Institute of Medical Sciences; 1999. |
|16.||Reddy SK, Gupta PC. Report on tobacco control in India. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2004. |
|17.||Government of India. National health accounts India. New Delhi, India: Ministry of Health and Family Welfare, Government of India; 2005. |
|18.||Human and income poverty: developing countries / Population living below $2 a day (%), Human Development Report 2009, UNDP. (Retrieved January 6, 2010 ) |
|19.||Government expenditure on health as a percentage of total government expenditure. Human Development Report 2009, UNDP. (Retrieved January 6, 2010 ) |
|20.||John RM. Tobacco consumption patterns and its health implications in India. Health Policy 2005;7:1213-22. |
|21.||Peters DH, Yazbeck AS, Sharma RR, Ramana G, Pritchett LH, WagstaffA. Better health systems for India′s poor. Finding analysis and options. Washington, USA: The World Bank; 2002. |
|22.||Gupta PC, Bhonsle RB, Mehta FS, Pindborg JJ. Mortality experience in relation to tobacco chewing and smoking habits from a 10-year follow-up study in Ernakulam District, Kerala. Int J Epidemiol 1984;13:184-7. [PUBMED] [FULLTEXT] |
|23.||John RM, Sung HY, Max W. Economic cost of tobacco use in India, 2004. Tob Control 2009;18:138-43. [PUBMED] [FULLTEXT] |
[Figure 1], [Figure 2], [Figure 3]
|This article has been cited by|
||Demystifying myths of cancer
| || Authors of Document Bisen, P.S. |
| ||Source of the Document Journal of Cancer Science and Therapy. 2013; |
||An overview of the tobacco problem in India
| || Authors of Document Mishra, G.A., Pimple, S.A., Shastri, S.S. |
| ||Source of the Document Indian Journal of Medical and Paediatric Oncology. 2012; |