The slow poison engulfing India

By Prof (Dr) Jaydip Biswas

Tobacco use is a major preventable cause of premature death and disease worldwide. Nearly one million people die in India every year due to tobacco use. Tobacco smoking is a major risk factor for many diseases, including cardiovascular disease (CVD), respiratory disease, and cancers at multiple sites. Tobacco use, including reverse smoking (smoking with the lit end inside the mouth), chewing of betel quid (a mixture of areca nut, slaked lime, and tobacco wrapped in betel leaf), and use of smokeless tobacco increases the risk of cancers of the upper aerodigestive tract. In the past few decades idequate public awareness of smoking risks, combined with aggressive marketing by tobacco companies, has resulted in a sharp increase in tobacco addiction in India.

In terms of tobacco habit, India is unique. In 17 states of India, tobacco use is more than 69 %. The North-Eastern region exhibits highest rates of tobacco use - in Mizoram more than 80 per cent of men use some form of tobacco, followed by Tripura (76 %) and Assam (72%). Aruchal Pradesh is the second largest state after Mizoram whose people chew tobacco products (Gupta 2006). Only 22% of total tobacco is consumed in India in the form of cigarettes, 54% is in the form of bidis and 24% is consumed in the form of chewing tobacco, pan masala, snuf, khaini, gutkha, masheri and tobacco tooth paste. These chewable tobacco products contain purified tobacco, paraffin, areca nut, lime, catechu and 230 permitted additives and flavours including known carcinogens.

According to GATS 2009-2010 the key features have been enlisted below-

1. The prevalence of tobacco use in India is very high and more than one-third (35%) of adults in India use tobacco in some form or the other.

2. The prevalence of overall tobacco use is 48 % among men and 20 % among women.

3. Among them 21 % adults use only smokeless tobacco, 9 % only smoke and 5 % smoke as well as smokeless tobacco.

4. The estimated number of tobacco users in India is 274.9 million.

5. There is significant variation in prevalence of both smoking and smokeless tobacco use in different regions and states. The prevalence of tobacco use among all the states and Union Territories ranges from the highest of 67 % in Mizoram to the lowest of 9 % in Goa.

6. Prevalence of tobacco use is higher among rural population as compared to urban and prevalence is found to decrease with increase in education level.

According to the Global Youth Tobacco Survey (GYTS, 2006), a total of 36.9% children in India initiate smoking before the age of 10. Among students 4.2% smoke cigarettes with rate for boys significantly higher than girls and 11.9% students use other tobacco products. Cigarette smoking among youth is higher in central, southern and north-eastern regions (12%). Exposure to second-hand smoke (SHS) in public places is as high as 40%.

Nearly 3000 chemical constituents have been identified in smokeless tobacco, while 4000 are present in tobacco smoke. These include alkaloids such as nicotine, nornicotine, cotinine, atabin, abasin; aliphatic hydrocarbons present in the waxy leaf coating and hundreds of isoprenoids that give the aroma to tobacco. Phytosterols such as cholesterol, campesterol, etc. and alcohols, phenolic compounds, chlorogenic acid, rutin, carboxylic acids and several free amino acids are present in tobacco. A wide range of toxic metals including mercury, lead, cadmium, chromium and other trace elements have been found in Indian tobacco. The alkaloids nicotine and nornicotine give rise to carcinogenic N-nitrosonornicotine (NNN), while another potent carcinogen 4-methylnitrosamino- 1-(3pyridyl)-1-butanone (NNK) is derived from nicotine. N-nitrosoatabin (T) and N-nitrosoabasin are other N-nitrosamines derived from the alkaloids abasin and atabin, respectively. Both NNN and NNK are present in high concentrations in smokeless tobacco and tobacco smoke.

Tobacco addiction is an established risk factor for cancers of the lung, head and neck (oral cavity, pharynx, larynx), sopharynx, esophagus, stomach, pancreas, liver, kidney, bladder, and cervix, and leukemia (IARC, 2012). Globally approximately 6.7 million smoking-related cancer cases are diagnosed every year of which 4.3 million cases are from developing countries.

The tobacco-related cancers constitute 56.4% and 44.9% of cancers in males and females, respectively.

There is no doubt that from view of public health point, this highly toxic industrial product needs strict control measures. The Government of India ected ‘Cigarettes and Other Tobacco Products (Prohibition of Advertisement and Regulation of Trade and Commerce, Production, Supply and Distribution) Act, 2003 (COTPA) to prohibit the consumption of cigarettes and other tobacco products, which are injurious to health. To strengthen the implementation of the tobacco control provisions under COTPA and policies of tobacco control mandated under the WHO FCTC, the Government of the India piloted tiol Tobacco Control Programme (NTCP) in 2007–2008.

The tiol Action Plan and Monitoring Framework for Prevention and Control of Non Communicable Diseases in India developed by Ministry of Health and Family Welfare aims to achieve a 20% reduction in current tobacco use by 2020 and 30% by 2025. A comprehensive study on the economic burden of tobacco related diseases was supported by the Ministry of Health & Family Welfare, Government of India, WHO Country Office for India and was developed by the Public Health Foundation of India (PHFI) in 2014. According to the report the total economic costs attributable to tobacco use from all diseases in India in the year 2011 amounted to Rs. 1,04,500 crores. The massive direct medical costs of tobacco attributable diseases amounted to Rs.16,800 crore and associated indirect morbidity cost was of Rs. 14,700 crore. The cost from premature mortality is Rs. 73,000 crores, indicating a substantial productive loss to the tion.

The tobacco problem in India is complex due to the varied ture of tobacco use. Cessation in Indian settings needs a multi discipliry approach which should include preventive, curative and rehabilitative care. Mass awareness activities in India should address adult and youth smokers as well as chewers. Educatiol interventions are very necessary in schools and colleges due to the large number of tobacco addicted children and teegers. Effective tobacco control in India is dependent on balanced implementation of demand and supply reduction strategies by the Government and stakeholder departments as well as on synergism of government policies and tobacco control initiatives by non government organisations. (PIB)