India

By Payal Shah, Karthik Subbaraman, and Prakash C Gupta
Healis – Sekhsaria Institute for Public Health, Navi Mumbai, India

The tobacco epidemic in India is the second-largest in the world. There are an estimated 250 million tobacco users in India. Each year 800,000 Indians die from tobacco-related diseases. Recent studies have estimated that tobacco use is increasing by about 3% each year. Almost half (47%) of adult men use tobacco and one in seven adult women (14%). The difference between male and female smoking rates is narrowing in some areas. Two in every 10 boys and one in every 10 girls aged 13–15 use tobacco.
Rates of adult male smoking and smokeless tobacco use are almost the same (30% vs 29%), whereas rates of adult female smoking are significantly lower than smokeless tobacco use (2.5% vs 12%). Prevalence of smokeless tobacco use among young people is almost twice that of smoking (15% vs 8.3%). All forms of tobacco use are more prevalent in urban areas compared to rural areas.

India is projected to have the fastest increase in tobacco-related deaths over the next 20 years compared to any other country. Tobacco-related deaths in India are projected to increase from 1.4% in 1990 to 13.3% in 2020. Cigarette and beedi smokers have 36% and 68% increased risks of death compared to non-smokers. Nearly 57% and 45% of the cancers in men and women are tobacco-related. There are about 12 million smoking-attributed COPD cases and an estimated 200,000 deaths are due to smoking in those with pulmonary tuberculosis in India. The total expenditure on tobacco-related cancer from, CAD, and COLD in 2001-2002 was approximately 310 billion rupee (INR).

India signed the FCTC in 2003 and was the eighth country to ratify it in 2004. Simultaneously, a comprehensive legislation “Cigarette and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Act, 2003 (COTPA 2003)” was enacted. Key provisions of the law include prohibition of direct and indirect advertisements of tobacco products; prohibition of smoking in public places; prohibiting the sale of tobacco products to minors; and legible display of pictorial warnings.

Unfortunately implementation barriers and exploitation of loopholes minimise the potential effects of these laws. Surrogate advertising is ubiquitous. Point-of-sale exceptions in the advertising ban and defiance of size restrictions have led to large adverting banners everywhere. Smoking sections lack a definition of “separate,” and thereby fail to protect the non-smoker. Since tobacco control is rarely a priority for the state and local governments, there is no enforcement mechanism and the laws are not implemented. Because of lack of knowledge and because there is no legal deterrent, the public does not comply.

Tobacco control advocates in India are currently working on issues such as smoke-free public and workplaces, and the implementation of pictorial warning labels. The tobacco control community needs to advocate with the government for improved policies. Furthermore, a strong coordinated network of NGOs and extensive NGO-government partnerships, along with more investment in research and evaluation, is required. Using scientific evidence NGOs can help government officials strategise effective awareness campaigns and policies.

With a focus on evidence-based policies and collaboration, the Bloomberg Initiative is forcing the Indian tobacco control community to think in terms of programmes and polices that work. This is important, not only to launch previously under-funded programmes, but to create a national dialogue about science-based strategies that will help curb India’s tobacco epidemic.

References
⁽¹⁾ Reddy K. Success of tobacco control in India: research as a lever for public policy. 2005 Available online here
⁽²⁾ Healthy-India.org http://healthy-india.org/notobacco.asp
⁽³⁾ Reddy K, Gupta P. Report on tobacco control in India, 2004 Ministry of Health and Family Welfare, Government of India.
⁽⁴⁾ Boyle P, Gray N, Henningfield J, Seffrin J, Zatonski W. Tobacco—science, policy and public health, 2004.
⁽⁵⁾ Prakash C Gupta. Tobacco Control in India. Indian Journal of Medical Research 2006; 123;579–582
⁽⁶⁾ The cigarette and other tobacco products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply, and Distribution) Bill, 2003.
⁽⁷⁾ WHO Framework Convention on Tobacco Control. World Health Organization.