Prevalence of Tobacco Products

Case Analysis Tobacco Prevalence

Tobacco Prevalence Analysis: Final Report

Prevalence of Tobacco Products: A Rural Indian Perspective

Prevalence of Tobacco Products

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Prevalence of Tobacco Products

Suggested Citation: This report is aimed to produce a brief summary of all the developments related to the authors case analysis, and acts as the Final submission

This report includes the entire work done for the case analysis during the Semester I and incorporates the first interim report as well as the Second Interim Report.

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Prevalence of Tobacco Products 1.1 BACKGROUND

Prevention of tobacco use and its de-addiction is receiving a high priority among policy makers in developed countries. With many parts of the globe being able to attain the tag of a tobacco free zone, India as a nation aspires to attain the same and all this is because of accumulation of irrefutable scientific data about the adverse consequences of tobacco use. WHOs tobacco free initiative and the Global Youth Tobacco Survey (GYTS) is a major effort to understand and document the problem and determinants of tobacco use in many countries. According to a nationwide study done in the year 2004 in India, on a sample of 152,000 individuals it was inferred that even daily consumption of tobacco products even in small amounts of is associated with increased mortality; chiefly from tuberculosis, other respiratory diseases, vascular diseases and neoplastic diseases. It was also statically inferred that 20% of male premature deaths and 5% of female premature deaths, occurring between the ages of 20 and 69 years, are attributable to tobacco consumption. In India, the ministry of health in collaboration with World health Organization has launched the Tobacco Free Initiative amongst all the states. However in still inspite of such a measure, tobacco smoking and chewing continue to be regarded as a relatively harmless social habit. Tobacco thus being a pressing problem of our society with dire health and economic consequences, it is important to expose the prevalence of tobacco products in rural zones as an harsh issue, by a method of scientific investigation which will result in a factual, quantitative picture of the problem. And since, in the recent times the tobacco sales in urban areas have dropped drastically, various tobacco companies have included rural regions of India into their focus. Thereby this study is an attempt to develop an effective intervention strategy to stop the rising use of tobacco products especially in the rural regions. 1.2 Study Objective Part 1

Use Primary Surveys in rural and urban regions of Pune with a sample space of 250 individuals and Estimate the extents of usage of tobacco products used (in terms of percent population) and also elicit the per capita/per capita monthly expense on tobacco products Part 2

Complete the Primary Survey, Relate the above statically derived parameters to wide spread use (in terms of percent population) and impact of tobacco use in rural regions in a comparative study with urban parts of Pune district in addition to identify the main reason for a prevalent use of tobacco products. Part 3

Develop an effective intervention strategy to stop the rising use of tobacco products primarily in the rural areas

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Prevalence of Tobacco Products

1.3

Limitations

As this study is based on very generic form of survey, the reliability of results derived from this study is function of multiple limitations as described under. 1. Data as collected for a very minor sample was considered applicable for a wide set of population. 2. Uncertainty in probability of data collection has not been accounted for In addition to above limitations additional limitations that govern the primary surveys also imply on this study. 2.0 PART 1 SURVEY

Part 1 of the study is primarily aimed to conduct a primary survey in rural and urban parts of Pune, targeting a cumulative sample space of 250 individuals and consecutively perform a basic data analysis on the acquired data to draw out primary inferences that could be used in further study. Part 1 of the study which was spread over a period of 30 days was disintegrated into following sub divisions for the sake of better persuasion of the concern. 1. Survey a. Rural Area b. Urban Area 2. Preliminary survey data analysis 2.1 2.11 Primary Survey Prefaces to Surveying The documentation depicted below is an attempt to explain the methodology adopted for surveying/interpretation, with a prime focus on explaining the nature and type of the questionnaire that was adopted in the survey protocol. The main source of inspiration for formulation of the survey methodology including the questionnaire and its interpretation was derived from multiple sources mentioned in the references and in particular a singular source was not followed.

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Prevalence of Tobacco Products It is also to be noted that, in order to maintain the consistency and comparability of tobacco use, a standardized set of questionnaire was used for both the urban and rural/sub-urban area, with the only region of difference lying in the type of approach to the population. 2.1.2 Overview of the questionnaire

The questions included in this survey were considered to be non-exhaustive, but served as a primary set to include the multiplicity of causes and its related governing factors. There were six basic set of questions that were used to measure tobacco prevalence and its associated effects, and it was considered that the data collected from these three basic set of questions will be sufficient to draw out the final conclusion of this study. All the major sections of the questionnaire used for the survey have been detailed below and areas pertaining to What the section actually carries, Why the section has been included and How the section has been measured have been included as under. (A) IDENTIFY: Prevalent type of tobacco products

The highest priority indicators are constructed from the three major questions which assess the prevalence of tobacco products. The first and the foremost question that identifies the type of usage of tobacco product in terms of following was questioned: 1. smoking tobacco 2. smokeless tobacco 3. Smoking and smokeless tobacco 4. non tobacco user The primary aim was to estimate the present percentage of population using tobacco products along with the type of usage and consecutively give a comparative overview of rural/sub-urban vs. urban prevalence in contrast to the data accounted by the 2004 national tobacco survey. Secondly, based on the responses (from the above four) of the respondents four sets of questioner were framed. All the four sets of questionnaires were identical in nature with the only difference lying within the way the questions were presented. (B) MONITER: Frequency of consumption

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Prevalence of Tobacco Products This segment of the questionnaire measures the amount of tobacco product being consumed by a consumer in terms of consumption frequency and it was mainly measured by two factors in terms of quantity and frequency. The primary aim to include this was to estimate the addiction pattern within the population under concern and compare the addiction pattern of rural/sub-urban vs. urban population. (C) RAISE: Economics tobacco product

As mentioned, tobacco consumption has a serious socioeconomic effect, thereby in order to elicit the degree of socioeconomic effect and present a clear picture of its impact on rural/suburban population this question was included. In this section a respondent was directly questioned on his/her financial expenditure on tobacco product. Secondly, for a better data interpretation, the socioeconomic effect was expressed in terms of expenditure on tobacco products over income in terms of percentage. (D) PROTECT: Exposure to second hand influence of tobacco product

On contrary to a popular belief that usage of a tobacco product in ones environment cannot effect ones decision to use a tobacco product, recent studies done by GATT indicate that an individual shall tend to be more inclined towards the usage of tobacco product if in case the same is used in his/her environment on a prevalent basis. In this study, exposure to secondhand environmental usage of tobacco product is considered as a major influencing factor that drives the temptation to adopt a tobacco product, thereby this question primarily analyzed the major influencing factors (in qualitative as well as quantitative terms) that drive an individual to adopt tobacco products (in case of an non user) or drive an individual to re-use a tobacco product (in case of an existing user) apart from the biological urge. This particular analysis was driven by questioning a respondent on two grounds: 1) Frequency of tobacco product used in residential environment 2) Frequency of tobacco product used in official environment (E) OFFER: Cessation

This section deals with the cessation tendencies of an individual who has been a tobacco user and primarily under this segment mainly two concepts were measured: Page | 7

Prevalence of Tobacco Products 1) 2) Attempt of current user to quit Advice from healthcare providers to quit

The main reason to include this question was to identify the anti-tobacco internal realization of a user, i.e. to estimate weather or weather not a tobacco user realizes the extent of damage that a tobacco product causes on his/her life. (F) WARN: Anti-tobacco information

This part of the questionnaire dealt with the access of an individual to the information pertaining antitobacco initiatives and aimed to consecutively assess the impact of same on the user. The important measures that were included in this section were: 1) 2) 3) Awareness of anti-tobacco information in newspaper/magazines/television Noticing of health warnings on tobacco packings Current user thinking about quitting because of health warnings.

The main aim to include this section was to identify the effectiveness of anti-tobacco information propagandized by the government and its effectiveness with the level of formal education that an individual possesses. (G) ENFORCE: Tobacco Promotion

Under this section, exposure of respondents towards tobacco promotions was measures in terms of: 1) Promotions The main reason to include this section as a part of the questionnaire was to elicit the effect of promotions of tobacco product on an individuals decision to adopt/continue the usage of tobacco products.

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Prevalence of Tobacco Products

2.1.3

Interpretation of the questionnaire

Tobacco Topic

Indicator Name and interpretation Current Tobacco users Percentage of respondents who currently use tobacco. Current Daily Tobacco users Percentage of respondents who currently use tobacco daily. Former Daily Tobacco users (Among All Adults) Percentage of respondents who are ever daily tobacco users and currently do not use tobacco. Former Daily Tobacco users (Among Ever Daily Smokers) Percentage of ever daily tobacco smokers who currently do not use tobacco.

MONITOR

Current tobacco status Past daily status Past tobacco status

PROTECT

Frequency of anyone using tobacco at home

Exposure to tobacco usage at Home Percentage of respondents who report that smoking occurs inside their home.

Work indoor/outdoor Anyone used tobacco at work during the past 180 days Exposure to tobacco usage at Work Percentage of indoor workers who were exposed to tobacco usage at work in the past 180 days.

Tried to quit in past 12 months OFFER

Tobacco Quit Attempt in the Past 12 Months Percentage of current tobacco users who tried to quit during the past 12 months. Health Care Providers Advice to Quit using Tobacco Percentage of current tobacco users who visited a doctor or health care provider during the past 12 months and were advised to quit tobacco.

Visiting a doctor in past 12 months Receiving advice to quit from doctor

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Prevalence of Tobacco Products

Noticing anti-tobacco information in newspapers or magazines

Awareness of Anti-tobacco Information in Newspapers/ Magazines Percentage of respondents who have noticed information about the dangers of using tobacco or that encourages quitting in newspapers or magazines in the last 180 days.

WARN

Noticing health warnings on cigarette packs

Noticing Health Warning Labels on tobacco Packages Percentage of current smokers who noticed health warnings on tobacco packages in the last 30 days.

Thinking about quitting because of health warnings

Thinking of Quitting Because of Health Warning Labels on packages Percentage of current tobacco users who reported thinking about quitting usage in the last 30 days because of the warning labels on packages.

Noticing tobacco advertisements in stores ENFORCE

Awareness of tobacco Advertising in Stores Percentage of respondents who have noticed any advertisements or signs promoting tobacco in stores where tobacco is sold in the last 180 days.

Noticing cigarette promotions

Awareness of Specific Types of tobacco Promotions Percentage of respondents who noticed [free samples of tobacco, tobacco at sales prices, coupons for tobacco, free gifts or discounts on other products when buying tobacco, clothing or other items with a tobacco brand name or logo, tobacco promotions in the mail] in the last 180 days.

Tobacco purchase cost

Tobacco Affordability Average cost of 100 packs of manufactured cigarettes/tobacco as a percentage of Gross Domestic Product (GDP) per capita.

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RAISE

Prevalence of Tobacco Products 2.1.4 Methodology overview (rural)

The author of this report accompanied by a local villager or a resident of local sub-urban zone (preferably a young men habituated to tobacco consumption in the age bracket of 18 -22) visited a nearby rural/suburban zones along with a questionnaire as detailed above was presented and filled onsite. If a particular individual was unavailable, the house was visited a second time and still if he is unavailable, information about him will be collected from the available family member. Physical from of questionnaire used for rural/sub-urban survey is depicted in exhibit 1.0. Target population was fixed to be 250 individuals. 2.1.5 Methodology Overview (urban)

The Urban data was collected primarily using an online survey coupled physical visits in the city of Pune. For the urban data collection an effective model of social-chain networking was used. Online survey from used for urban survey is depicted in exhibit 2.0.Target population was fixed to be 250 individuals. 2.2 Data Presentation and Brief Analysis (URBAN)

The author of this interim report regrets to inform that instead of a total target population of 500 individuals, only 257 was achieved. The number of urban individuals surveyed was 156. The below given data analysis is for the 156 urban collections and it is expected that the inferences form the below analyzed data are likely to remain unaltered even if the target number of individuals could have been surveyed. 2.2.1 MONITOR Analysis Ratio of tobacco consumption (urban)
tobacco user tobacco non-user

34%

66%

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Prevalence of Tobacco Products The above infers that a majority chunk of the urban population does not use tobacco products. But as the 34% of population can be classified as a tobacco user, this 34% infers to a huge number of individuals habituated to tobacco use which converts to a huge section of revenue for tobacco companies. This indicates higher degree of self awareness among the urban individuals.

Types of tobacco consumed (urban)

11% 12% smoking tobacco smokeless tobacco 77% smoking and smokeless tobacco

As expected the analysis of the survey reveals that out of all the tobacco consumers the maximum population segment is attributed to tobacco smokers. This indicates extensive use of smoking products.
Consolidated Usage (urban)
User Non- User Smoker Chewer

28% 67% 33% 5%

0%

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Prevalence of Tobacco Products Recurrence of tobacco usage (urban)

50 45 40 35 30 25 20 15 10 5 0 Daily 5 Weekly 4 Monthly 1 less than monthly 43

The above chart infers to a conclusion that the maximum number of tobacco consumers consume tobacco products on a daily recurrent basis. This indicates the addiction tendencies among the tobacco consumers. 2.2.2 PROTECT Analysis
Exposure to tobacco at residing place (urban)

9% 6%

Daily exposure Weekly exposure no exposure

85%

It is clearly indicative that majority of the tobacco consumer are exposed to daily exposure in their residential areas. This indicates that one of the reasons governing recursive use can be attributed to exposure to tobacco products at residing places. Page | 13

Prevalence of Tobacco Products

Exposure to tobacco at working place(urban)

Daily exposure Weekly Exposure No exposure

2%

11%

87%

It is clearly indicative that majority of the tobacco consumer are exposed to daily exposure in their working areas. This indicates that one of the reasons governing recursive use can be attributed to exposure to tobacco products at working places. 2.2.3 OFFER Analysis
Tried to quit in past 12 months (urban)
Didn't Try Tried but, didn't seek medical assistance tried Tried and sought medical assistance

26, 49%

27, 51%

27, 51%

0, 0%

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Prevalence of Tobacco Products It is not surprising to see that nearly 50% of tobacco users do realize the demerits of tobacco use and have tries to quit the same. But, it is very surprising to see that none of the individuals who wish to quit tobacco usage have taken a medical advice for the same. 2.2.4 WARN Analysis
Types and extent of noticed tobacco warnings (urban)

45 40 35 30 25 20 15 10 5 0 Print Media Televissions Packings Types and extent of noticed tobacco warnings

As expected, all of the urban tobacco users have noticed warnings on the packets of tobacco products or have encountered the same in news papers or televisions.
Effect of warning on motivation to quit (urban)

15%

Possitive effect No Effect

85%

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Prevalence of Tobacco Products It was very surprising to see that only 15% of individuals who have noticed warnings have been motivated to quit the tobacco use, thereby questioning the methodology in anti-tobacco drives. 2.2.5 ENFORCE Analysis

Percentage of surveyed population noticed tobacco promotions (urban)

40% Promotions Noticed Promotions not noticed 60%

Inspite of strict anti-promotion policy, it was found that 60% of the individuals have noticed tobacco promotions. This again questions the enforcement of anti-tobacco policy by the government.
Types of promotions noticed (urban)
100 80 60 40 20 0

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Prevalence of Tobacco Products The above data representation clearly indicates innovative marketing practices by the manufactures of tobacco products. With e-mail based promotions leading the pack. 2.3 Data Presentation and brief Analysis (Rural)

The author of this interim report regrets to inform that instead of a total target population of 500 individuals, only 257 was achieved. The number of urban individuals surveyed was 101. The below given data analysis is for the 101 urban collections and it is expected that the inferences form the below analyzed data are likely to remain unaltered even if the target number of individuals could have been surveyed. 2.3.1 MONITOR Analysis Ratio of tobacco consumption (rural)
tobacco user tobacco non-user

37%

63%

The above infers that a minority chunk of the rural population does not use tobacco products. But as the 64% of population can be classified as a tobacco user, this value though might not infer to a lot many individuals, but certainly should be a point of concern for the government.

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Prevalence of Tobacco Products

Types of tobacco consumed (rural)

30% smoking tobacco 56% 14% smokeless tobacco smoking and smokeless tobacco

As expected the analysis of the survey reveals that out of all the tobacco consumers the maximum population segment is attributed to combined tobacco user. This indicates extensive use of smoking as well as non-smoking tobacco products. Recurrence of tobacco usage (rural)
60 50 40 30 20 10 7 0 Daily Weekly 0 Monthly 1 less than monthly

56

The above chart infers to a conclusion that the maximum number of tobacco consumers consume tobacco products on a daily recurrent basis. This indicates the addiction tendencies among the tobacco consumers.

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Prevalence of Tobacco Products 2.3.2 PROTECT Analysis

Exposure to tobacco at residing place (rural)

10% 9% Daily exposure Weekly exposure no exposure

81%

It is surprisingly indicative that majority of the tobacco consumer are not exposed to daily exposure in their residential areas. This indicates that reasons governing recursive use may not attributed to exposure to tobacco products at residing places.
Exposure to tobacco at working place (rural)
Daily exposure Weekly Exposure No exposure

13% 9%

78%

It is clearly indicative that majority of the tobacco consumer are exposed to daily exposure in their working areas. This indicates that one of the reasons governing recursive use can be attributed to exposure to tobacco products at working places. Page | 19

Prevalence of Tobacco Products 2.3.3 OFFER Analysis

Tried to quit in past 12 months (rural)
Didn't Try Tried but, didn't seek medical assistance tried Tried and sought medical assistance

58, 91%

6, 9%

6, 9%

0, 0%

It is not surprising to see that nearly 90% of tobacco users (rural) do not realize the demerits of tobacco use and havent tried to quit the same. But, it is very surprising to see that none of the individuals who wish to quit tobacco usage have taken a medical advice for the same. 2.3.4 WARN analysis
Types and extent of noticed tobacco warnings (rural)

30 25 20 15 10 5 0 Print Media Televissions Packings Types and extent of noticed tobacco warnings

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Prevalence of Tobacco Products As expected, only a few of the rural tobacco users have noticed warnings on the packets of tobacco products or have encountered the same in news papers or televisions. This calls for more intensive enforcement of anti-tobacco drive in rural area.
Effect of warning on motivation to quit (rural)

9%

Possitive effect No Effect

91%

It was very surprising to see that only 9% of individuals who have noticed warnings have been motivated to quit the tobacco use, thereby questioning the methodology in anti-tobacco drives. 2.3.5 ENFORCE Analysis
Percentage of surveyed population noticed tobacco promotions (rural)

40% Promotions Noticed Promotions not noticed 60%

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Prevalence of Tobacco Products Its not very surprising to notice that 40% of rural individuals have notice the tobacco promotions; majority chunk of the rural population is habituated to the usage of tobacco products.
Types of promotions noticed (rural)
30 20 10 0

The above data representation clearly indicates slowly accelerating marketing practices by the manufactures of tobacco products, where they are slowly shifting their focus on rural domains. 2.4 Summary of Conclusions drawn out of survey data analysis 1. Only male respondents claimed to have been habituated to tobacco use. 2. Higher percentage of rural population is habituated to the use of tobacco products. 3. In urban regions prime use of tobacco products is in form of smoking tobacco while in case of rural areas the tobacco consumption is mainly attributed to joint use of smoking/smokeless tobacco. 4. A common tendency has been noticed in terms of frequency of usage of tobacco products with a distinctive dominance of daily in both rural as well as urban. 5. With work place related exposure to tobacco products governing the rural part a clear insight of role play of residential exposure in case of urban area is indicated. 6. A realization to quit the use of tobacco products has been depicted in urban area, while the same is minimal in case of rural area. A very noticeable factor is that nearly none of the respondents have shown an indication of visiting a health care specialist in regard to their tobacco habits.

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Prevalence of Tobacco Products 7. It is clearly inferable that a large chunk of urban population has been affected by the promotion activities of the tobacco manufactures. 8. Adults living in the most rural areas have the highest prevalence rates for smoking. 9. This trend reflects two factors, delayed access to medical resources and lower educational attainment. 10. Smokeless tobacco use is also more prevalent among adults in rural settings particularly among young males aged 18 to 24 years. 11. There is evidence suggesting that smoking rates among rural pregnant women remain higher than smoking rates among urban pregnant women. 12. Tobacco-related illnesses as a result of exposure to tobacco products are present in both rural and urban settings; however, some evidence suggests a great acceptance of tobacco illness rural settings. 13. Therefore, our expectation to find a higher prevalence of tobacco consumption and related illnesses in rural settings, though sufficient survey has been proved to be correct

14. Studies conducted in rural areas indicate the most common reasons for tobacco use
in rural areas are a lack of knowledge, issues related to susceptibility, and modeling of the social environment. 15. It has also been noticed and proved that the tobacco companies have now started targeting the rural populations and the affect of the same is noticeable. This is mainly governed by rural population relating lifestyle goods to tobacco products. 2.5 Inference drawn out of survey data analysis (Reasons for prevalent use)

A number of factors influence the use of tobacco by children and teenagers. Some of these are the family history of tobacco use by elders, peer influence, experimentation, easy access to such products, personality factors, underlying emotional and psychological problems, accompanied risk-taking behaviors, and most importantly, the aggressive marketing strategies of the tobacco industry. Based on the analysis of non-quantity data/quantitive data, briefed following is a detailed discussion on Factors Leading to of Tobacco Use 1) The role of family Family plays a very important role in initiation of tobacco use by a young child or adolescent. Tobacco use by parents or an elder sibling increases the likelihood that a child begins tobacco Page | 23

Prevalence of Tobacco Products consumption. As an example, many Indian fathers and grandfathers frequently ask the boys to fetch tobacco derivatives from a nearby shop or kiosk. By this way, children are often introduced to such products at their very early life stages. A child growing in such a family watching his elder brother, father, uncles or grandfather using tobacco may perceive it as a family tradition that is to be followed. On the other hand, it is interesting to know that as an Indian tradition, younger individuals are not expected to consume tobacco in the presence of elderly, because smoking by a younger person is taken as in contempt of the older people. Therefore, it is a paradox that the same elderly people, who passively show the way to smoke, are prohibitive of the same behaviour by the younger generation in their own presence. However, this value system does apply to the use of smokeless tobacco products. 2) The role of peer influence Although children may start smoking for psychosocial reasons like peer influences, curiosity, desire for experimentation or as a remedy for stress, the pharmacological motives take on place very early in their smoking career. Consequently, by the time children consume tobacco on a daily basis, they take up the same amount of nicotine from each product as their adult counterparts do. 3) Easy availability of tobacco products Tobacco products are socially sanctioned but are freely available in every nook and corner throughout our survey region. Beedis/chewable tobacco is a bit cheaper than the tobacco and hence is preferred by the poor who cannot afford tobacco. 4) Lateral/other Psychological/emotional factors Poor school performance, truancy, low aspiration for future success, and school dropouts has been found to be associated with smoking at an early age. Children and adolescents with anxiety and depression are likely to use tobacco and other drugs, as these have anxiety relieving and mood elevating properties. Furthermore, such children may socially be anxious and feel isolated in a company of peer groups. Initiation of tobacco consumption helps them to identify with the group and hence reduces social anxiety. Children with low self-esteem are likely to be vulnerable to drug use including the tobacco. As smoking behaviour is associated with maturity and adulthood, tobacco use may serve to promote self-esteem. 5) Promotion by tobacco companies Page | 24

Prevalence of Tobacco Products Advertisements of various tobacco products are very common in all forms of media including the print media, television, and the roadside hoardings and banners. Tobacco advertising and promotion effectively target the young people with images of smokers as trendy, sporty and successful. Characters in the movies or television serials often demonstrate cigarette smoking as a routine of daily life. They sometimes even show cigarette lighting ways using different tricks. These scenes often attract the impressionable mind of the adolescent to use similar tricks or adopt similar behavior. For a child or an adolescent growing in a stressful home, television show and movies are a means of finding out what a normal life is about. He or she is likely to begin tobacco consumption after watching such visuals. Some multinational companies are also involved in sponsoring tobacco of mega sport events like international cricket matches and some even have instituted bravery awards. These attract the vulnerable child or adolescent towards smoking with an idea that it may be a heroic or desirable activity to adopt because of the apparent positive associations. Advertisements and promotion of tobacco have been reaching its peak in rural India due to a sharp decline in sales in urban area. To summarize, multiple factors determine initiation of tobacco use. These factors are both promoting and prohibitive and have been constantly changing over the time depending on several economical and marketing forces. Traditionally, tobacco consumption had an association with the upper class of the society, reminiscent of the British colonial era. Though in the recent past it has percolated to all strata of the society, it is still more common among the upper and middle classes. Among the lower income groups, smokeless tobacco like khaini, mishri or smoking beedis are common. In rural areas, smoking by hooka and tobacco chewing are common. Over the last 23 decades, particular chewable tobacco products are being highly promoted for sale and their use is being linked with the society's upper-class business-community in order to popularize them among the masses. Therefore, the socio-cultural influences are quite complex in these regards and in establishing changes in tobacco use among the public. 2.6 CONCLUSION of work done from 1st Interim Submission to 2nd Interim Submission

Humans have used tobacco in many forms for several centuries. Its use often starts early in life. In recent years, there has been a rising trend in tobacco use, more in smokeless forms in rural India. There are no nationwide data available in India on the exact extent of the tobacco use among adolescents, although a number of surveys have been conducted as detailed above. These surveys show a general tendency towards a higher tobacco use by the rural population for the past few decades (in terms of percent population studied), with an emphasis on the use of smokeless tobacco. This is a matter of great public Page | 25

Prevalence of Tobacco Products health concern. Psychosocial factors have an important role to play in initiation of this habit. It has been observed that a large number of adolescents pick up this habit from their family members or the peers. Advertisements of tobacco products and promotional campaigns by the manufacturers also play an important role in initiation of the habit by adolescents. This has attracted the attention of health professionals, media and law enforcement agencies. The local governments are also taking steps in putting curbs over the sales of tobacco products (e.g recent ban of same of gutka) , and in regulating tobacco advertisements. There is a need to collect nationwide data on the use of different forms of tobacco by rural population, and the factors leading to initiation of such harmful habits. There is an dire need to take effective steps, especially on launching community awareness programs for the school children and public to educate them about the consequences of tobacco use, and on assessing their effectiveness in curbing the problem. It is also necessary to keep abreast of the policies and conventions of the international agencies like WHO, UNDCP and other similar agencies on tobacco use, in order to utilize their expertise for curbing this problem.

3.0

PART III - PREVENTIVE STRATEGIES

Considering the enormous adverse health consequences accompanying tobacco addiction, it is very important to develop preventive strategies to reduce tobacco consumption. Preventive strategies especially focused towards rural population need to be initiated. This is more important for the rural areas, which have become the main targets of advertisement and promotional propaganda of various multinational tobacco companies. 3.1 Restricting Minors Access to Tobacco Products:

Access to tobacco products by minors (people under 18 years of age in most states) contributes to the initiation and regular use of tobacco by children and adolescents. Retailers who sell tobacco products to minors (including vending machines in accessible settings)

constitute one avenue of access for minors. Social sources provide another route of access for many, but not all, minors. Although social sources include adults (parents, family, and friends) who may purchase tobacco products legally, illegal retailer sales to minors provide tobacco products for distribution to other minors, contributing to social access. Minors obtain Page | 26 tobacco from commercial sources through face-to-face purchases from

Prevalence of Tobacco Products retailers (from self-service displays or requests for products held behind the counter),

purchases from vending machines, purchases through the mail or over the Internet, access to free product samples, and theft from retail sources. Overall, minors access reflects the availability of tobacco products within the community, the willingness of retailers to sell them, and the efforts of minors to obtain them. Interventions to reduce access attempt to modify or to change one or more of these factors. This section includes a review of a variety of interventions to restrict and reduce the supply of tobacco products that minors can obtain from commercial sources. Some of the intervention combinations reviewed included components intended, in whole or in part, to reduce the demand for tobacco products by minors through efforts to educate and mobilize the

community and to change social norms about the acceptability of tobacco use. In these efforts, minors access to commercial sources of tobacco provided a focus for the community to address the problem of tobacco use among youth. 3.1.1 Sales Laws Directed at Tobacco Retailers to Reduce Illegal Sales to Minors In addition to general laws governing the sale of tobacco, laws directed at retailers provide specific regulation or restriction of the sale of tobacco products to minors. These laws include licensing requirements for tobacco retailers and bans or

restrictions on tobacco product vending machines and self-service displays. The laws may include additional conditions, such as requiring proof of the purchasers age before selling tobacco, displaying sales laws (such as warning signs at the point of purchase), banning the sale of single cigarettes, and restricting the age of the seller. These laws may designate the method of enforcement and establish the penalties and the responsible parties for each violation (for example, civil penalties

directed at the retail owner or license holder). 3.1.2 Laws Directed at Minors Purchase, Possession, or Use of Tobacco Products These laws prohibit the purchase, possession, or use of tobacco products by minors. Communities have implemented laws directed at minors, and state governments are increasingly doing so. The laws may designate which agency is responsible for enforcement as well as the penalty for violations. Some laws require minors who have received citations to participate in educational programs that provide assistance Page | 27

Prevalence of Tobacco Products in quitting smoking. 3.1.3 Retailer Education with Information on Health Consequences These interventions aim to increase retailer compliance with prohibitions on tobacco sales to minors through repeated educational messages and feedback on retailer performance. Reviewed interventions involved face-to-face delivery of education messages by concerned citizens, health department workers, or law enforcement officers. The educational component included follow-up that provided either positive or negative reinforcement of retailer or clerk compliance with sales laws based on periodic unannounced compliance checks. In most cases, these interventions included information on the health consequences of tobacco use. 3.1.4 Community Education about Minors Access to Tobacco Products These interventions attempt to disseminate information community-wide to focus public attention on the issue of youth access to tobacco products. The educational components include community-wide assessments of compliance by tobacco

retailers, with results disseminated through mass media events, news coverage, and presentations to civic groups and local governments. The interventions can also include community and school meetings and activities as well as direct contact with local governments through testimony, petitions, letters, and phone calls. In this review, we distinguished between community education efforts (reviewed here) and community mobilization, in which the education efforts fostered or were coordinated with additional interventions directed at minors access to tobacco products. 3.2 Increasing Tobacco-Use Cessation

Interventions to increase the number of tobacco users who successfully quit include efforts to increase the number of people who attempt to quit, efforts to improve the success rate for quit attempts, and efforts that support both of these goals. We reviewed two approaches appropriate for communities (increasing the unit price for tobacco products and mass media education); two approaches that can be implemented in healthcare systems (provider reminder systems and provider feedback systems; and one intervention appropriate for both communities and healthcare systems (telephone cessation support). Page | 28

Prevalence of Tobacco Products In conducting this review of the evidence, we noted that spontaneous and unassisted rates of tobacco use cessation among tobacco users are low (3%10%). The interventions reviewed in this section can show relatively large improvements in the success rates for tobacco use cessation. 3.2.1 Increasing the Unit Price for Tobacco Products Excise tax increases at the municipal, state, or federal level can raise the unit price for tobacco products. In several states, excise tax increases on tobacco products resulted from successful state ballot initiatives. Although other factors affect tobacco product pricing, excise tax increases have historically resulted in an equivalent or larger increase in tobacco product prices. Effectiveness: Increases in tobacco product price are consistently effective in reducing tobacco use (a 10% price increase results in approximately a 4% decrease). Price increases also reduce tobacco use among adolescents and young adults. Barriers: Increasing the excise tax on tobacco products requires passage of legislation or a statewide referendum. A positive effect of increasing the unit price for tobacco products is a decrease in tobacco use among adolescents and young adults (discussed under Reducing Tobacco Use Initiation). One potential negative effect of increases in tobacco product excise taxes is an increase in smuggling (illegal cross-border transport and sale of untaxed tobacco products). In conclusion, the Task Force recommends increasing the unit price for tobacco products on the basis of strong evidence of effectiveness in increasing the number of people who stop using tobacco. Raising the unit price for tobacco products, through increases in excise taxes for tobacco products, is consistently effective in reducing tobacco use, regardless of the measure used. 3.2.2 Mass Media Education Mass media messages (broadcast and print) are disseminated to provide cessation information, motivation to assist tobacco users in their efforts to quit, or both. In our review, we distinguished among three subtypes of mass media interventions

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Prevalence of Tobacco Products campaigns, cessation series, and cessation contestswhich differ in the duration, intent, and intensity of the media messages. Each is addressed separately below. 3.2.2.1 Mass Media Education Campaigns Combined with Other Interventions Mass media campaigns employ brief, recurring messages over time (weeks to years) to provide information or motivation to tobacco users and others (family members, households, peers) with the goal of increasing or improving efforts to quit using tobacco products. The messages, developed through formative research, are

disseminated through paid broadcast time and print space, donated time and space (as public service announcements). Campaigns can focus on cessation or can include cessation themes within a broader range of tobacco messages (including messages directed at reducing tobacco use among youth, reducing secondhand smoke exposure, or both). Mass media campaigns can be combined with other interventions, such as an excise tax increase or additional community-wide education efforts. 3.2.2.2 Mass Media EducationCessation Series Cessation series consist of broadcasted instructional segments designed to recruit, inform, and motivate users of tobacco products to try quitting and to succeed. Cessation series can be coordinated with pre-series broadcast or print promotion,

community education (e.g., distribution of self-help cessation materials), and organization of cessation groups in the community. The series can extend for a period of several weeks to several months. Techniques include nightly or weekly segments on news or informational programs giving expert advice or sharing peer group experiences on cessation issues (e.g., dealing with the symptoms of withdrawal). The series can encourage tobacco users to join a community-wide quit effort. Over the course of the broadcasts, viewers can receive ongoing support and assistance from cessation experts and recruited peers. 3.2.2.3 Mass Media EducationCessation Contests Cessation contests are community-wide events of short duration that use mass media to recruit and motivate users of tobacco products to participate in a program to quit by a certain date or during a specified time period. Cessation contests use both mass media and such small media as posters and fliers as the primary tool for promotion and to recruit tobacco product users in the community. Contests can Page | 30

Prevalence of Tobacco Products increase cessation in the community by changing tobacco product users attitudes about cessation, recruiting users to initiate a quit attempt, and motivating those who attempt to quit to remain abstinent through incentives or by mobilizing support from family, friends, and other participants. We evaluated contests that offered

additional incentives for participation and successful cessation, as well as targeted quit events conducted without additional incentives. 3.2.3 Healthcare Provider Reminder Systems Provider reminder systems can identify clients who use tobacco products and prompt providers to discuss cessation with their clients or advise clients to quit at every encounter. Because even brief provider advice has an effect on getting clients to quit, increasing the delivery of advice by providers should increase the number of clients who quit. Reminders can be delivered by a variety of methods, including chart stickers, vital sign stamps, medical record flow sheets, and checklists, and the con- tent of the reminders can vary. Provider reminder systems are often combined with other interventions, such as provider education and client education. 3.2.4 Healthcare Provider Feedback and Assessment Feedback interventions inform and motivate providers by assessing their performance in identifying client tobacco use status, delivering advice to quit, or both. Assessment techniques include chart reviews and the use of computerized records. These interventions can be combined with other activities, such as provider reminders and provider education. Provider assessment and feedback can motivate providers to increase and improve their interactions with clients in such areas as advising clients to stop using tobacco. Evaluation of provider assessment and feedback is timely information systems are improving and because (1) clinical effective

are increasingly common; (2)

cessation therapies are available, and an increase in provider interactions with tobacco-using clients could increase the use of these therapies. 3.2.5 Multi-component Interventions That Include Client Telephone Support

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Prevalence of Tobacco Products Telephone support for people trying to stop using tobacco provides counseling or assistance in quitting and in staying tobacco-free. Depending on the program,

tobacco users or healthcare providers can initiate contact. Telephone support can include trained counselors, healthcare providers, or taped messages in single or multiple sessions that usually follow a standardized protocol for providing advice and counseling. Telephone support is usually combined with other interventions, such as client education materials, individual or group cessation counseling, or nicotine replacement therapies. Telephone contact is intended to increase the motivation of tobacco users to attempt to quit, and can help to reduce relapse by providing support and assistance to recent quitters. In community settings, telephone support typically provides access to selfhelp cessation materials and available local resources (such as group sessions), and may provide counseling and motivation sessions. In clinical settings, telephone follow-up calls usually support other clinical cessation interventions such as provider counseling, group cessation sessions, or nicotine replacement or other therapies. 3.2.6 Reducing Exposure to Environmental Tobacco Smoke Interventions to reduce exposure to environmental tobacco smoke (ETS) require or encourage the establishment of smoke-free areas in workplaces, in public areas, and in the home in an effort to reduce tobacco-related morbidity and mortality. Having smoke-free areas can reduce exposure to ETS and ETS-related illness and death. Smoke-free policies can change the attitudes and behaviors of smokers and increase both the number of people who try to quit and the number of attempts made by each person. Smoke-free policies may also improve the success rate for each quit attempt by reducing opportunities for relapse. Smoke-free policies also challenge the perception of smoking as a normal adult behavior. By changing this perception, these policies can change the attitudes and behaviors of adolescents, resulting in a reduction in tobacco use initiation. The interventions reviewed here are smoking bans and restrictions to address

exposure in the workplace and in public areas and community education to reduce exposure to ETS, especially among children, in the home environment. 3.2.6.1 Page | 32 Smoking Bans and Restrictions

Prevalence of Tobacco Products Smoking bans and restrictions are policies, regulations, and laws established by private, nongovernment, and government groups and agencies. Smoking bans entirely prohibit smoking in geographically defined areas, whereas smoking restrictions limit smoking to designated areas. Smoking bans and restrictions can be implemented with additional interventions, such as education and tobacco use treatment programs. Businesses establish smoking policies to protect employees and customers from exposure to ETS in the workplace. Accrediting agencies (set regulations to protect employees and patrons within their organizations. National, state, or local laws are implemented to protect people from ETS exposure in public areas, and to establish minimum standards for both public and private workplaces. Standards for

regulations and laws establishing smoking restrictions often include the size, location, and ventilation requirements for designated smoking areas. 3.2.6.2 Community Education to Reduce Exposure to E.T.S in the Home Community education includes all efforts to increase knowledge and to change attitudes about the (ETS). health effects of exposure to environmental tobacco smoke

Techniques may include mass media messages, small media messages

(including educational materials), and counseling provided outside of healthcare settings. Community education provides information to parents, other occupants, and

visitors about the health risks for nonsmoking adults and for children caused by smoking in the home. Information is disseminated to households to motivate (1) tobacco users to reduce exposures to ETS in the household by quitting or by smoking outdoors, (2) nonsmokers in the household to assist smokers in their efforts to quit, and (3) members of the household to establish home smoking bans or restrictions. The combination of reduced indoor smoking and increased cessation will result in a reduction in indoor ETS exposure and, therefore, a reduction in tobacco-related illness. 3.3 CONCLUSION of work done from Second Interim Submission to Final Submission

This chapter summarizes conclusions and recommendations to date from the Authors on interventions to reduce the initiation of tobacco use, to increase tobacco use cessation, and to Page | 33

Prevalence of Tobacco Products reduce exposure to ETS. To reduce the initiation of tobacco use, the Authors recommends increasing the unit price for tobacco products; mass media education campaigns combined with other interventions; and community mobilization combined with additional interventions to restrict minors access to tobacco products. Evidence was insufficient to determine the effectiveness of restricting minors access to tobacco through the following interventions when implemented alone: sales laws directed at retailers; laws directed at minors purchase, possession, or use of tobacco products; active enforcement of sales laws; retailer education with reinforcement; retailer education without reinforcement; and

community education. To increase cessation of tobacco use, the Authors recommends increasing the unit price for tobacco products; mass media campaigns combined with other interventions; healthcare provider reminder systems; provider re- minders combined with provider education; reducing client out-of-pocket costs for effective cessation therapies; and multi-component interventions that include client telephone support (quit lines). Evidence was insufficient to determine the effectiveness of mass media cessation series; mass media cessation contests; healthcare provider education alone; and healthcare provider feedback and assessment. To reduce exposure to ETS, the Authors recommend smoking bans and restrictions. Evidence was insufficient to determine the effectiveness of com- munity education to reduce exposure to ETS in the home.

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Prevalence of Tobacco Products 4.0 References

Thun MJ, CA Day-Lally, EE Calle, WD Flanders and CW Heath (1995): Excess mortality among cigarette smokers: changes in a 20-year interval, American Journal of Public Health. Jha Prabhat, et.al. (2008): A Nationally Representative Case-Control Study of Smoking and Death in India, The New England Journal of Medicine, 358, 1137-47. Gajalakshmi V. R. Peto, T Kanaka, P Jha : Smoking and mortality from tuberculosis and other diseases in India : retrospective study of 43000 adult male deaths and 35000 controls, The Lancet. Wald, NJ and AK Hacksaw (1996): Cigarette smoking: an epidemiological overview, British Medical Bulletin. Stahl SM (2008): Disorders of Reward, Drug Abuse, and Their Treatment, Stahls Essential Psychopharmacology, pg 968, Cambridge University Press. Jarvis M (2000): Patterns of use, epidemiology, adverse effects, and specific issues concerning treatment for nicotine dependence, New Oxford Textbook of Psychiatry, Vol1, Oxford University Press. 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. Singh S, Suganthi P, Ahmed J & Chadha V (2005): Formulation of health research protocol a step by step description, NTI Bulletin. Bartlett JE II, Kotrlik JW, Higgins CC (2001): Organizations research determining appropriate sample size in survey research, Information Technology, Learning, and Performance Journal. Sundar Rao PSS & Richard J (1997): An introduction to biostatistics, Prentice Hall of India. Backstrom CH, Hursh GD (1980): Survey research, Northwestern University Press.

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Prevalence of Tobacco Products 5.0 Contact Information

For quarries on this document please contact: Authors: Divya Prakash MBA-I Roll No. 35285 Aniruddha Kumar Ghodh MBA-I Roll No. 35265

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Prevalence of Tobacco Products 3.0 Questionnaire for rural population Smoking Tobacco P1 A: G:
How often do you currently smoke tobacco? DAILY LESS THAN DAILY On average, how many tobacco products do you currently smoke each day? On average, how much do you monthly spend on tobacco smoking? How often does anyone smoke inside your living place? DAILY WEEKLY LESS THAN MONTHLY NEVER During the past 6 months, did anyone smoke in indoor areas where you work/study? YES NO

Exhibit 1

P2 A: G:

P3 A: G:

P4 A: G:

P5 A: G:

P6 A: G:

P7 A: G:

During the past 12 months, have you tried to stop smoking? YES NO Have you visited a doctor or other health care provider w.r.t smoking concerns in the past 12 months? YES NO In the last 6 months, have you noticed information that encourages quitting in newspapers or in magazines? YES

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NO

Media not accessible

In the last 6 months, have you noticed information about the dangers of smoking cigarettes or that encourages quitting on television? YES NO

Media not accessible

In the last 6 months, did you notice any health warnings on cigarette packages? YES NO DID NOT SEE ANY CIGARETTE PACKAGES In the last 6 months, have warning labels on cigarette packages led you to think about Quitting? YES NO In the last 6 months, have you noticed any advertisements or signs promoting cigarettes in stores where cigarettes are sold? YES NO In the last 6 months, have you noticed any of the following types of cigarette promotions? a. Free samples of cigarettes? b. Cigarettes at sale prices? c. Coupons for cigarettes? d. Free gifts or special discount offers on other products when buying cigarettes? e. Clothing or other items with a cigarette brand name or logo? f. Cigarette promotions in the mail?.

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Prevalence of Tobacco Products Non-Smoking Tobacco P1 A: G:

How often do you currently chew tobacco? DAILY LESS THAN DAILY On average, how many grams of tobacco products do you currently chew each day On average, how much do you monthly spend on tobacco chewing? How often does anyone chew tobacco inside your living place? DAILY WEEKLY MONTHLY LESS THAN MONTHLY NEVER During the past 12 months, have you tried to stop chewing tobacco? YES NO Have you visited a doctor or other health care provider w.r.t tobacco chewing concerns in the past 12 months? YES NO In the last 6 months, have you noticed information about the dangers of chewing tobacco or that encourages quitting in newspapers or in magazines? YES NO

P2 A: G:

P3 A: G:

P4 A: G:

P5 A: G:

P6 A: G:

P7 A: G:

Media not accessible

In the last 6 months, have you noticed information about the dangers of chewing tobacco or that encourages quitting on television?

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Prevalence of Tobacco Products

YES NO

Media not accessible

In the last 6 months, did you notice any health warnings on chewable tobacco packing? YES NO DID NOT SEE ANY CIGARETTE PACKAGES In the last 6 months, have warning labels on chewable tobacco packages led you to think about Quitting? YES NO In the last 6 months, have you noticed any advertisements or signs promoting chewing tobacco in stores where chewable tobacco is sold? YES NO In the last 6 months, have you noticed any of the following types of chewable tobacco promotions? a. Free samples of chewable tobacco? b. chewable tobacco at sale prices? c. Coupons for chewable tobacco? d. Free gifts or special discount offers on other products when buying chewable tobacco? e. Clothing or other items with a chewable tobacco brand name or logo? f. chewable tobacco promotions in the mail?. The last time you bought chewable tobacco for yourself, how many grams(approx.) of tobacco did you buy?

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Prevalence of Tobacco Products

Smoking and smokeless tobacco P1 A: G:

How often do you currently use a tobacco product? DAILY LESS THAN DAILY On average, how many tobacco products do you currently use per day? On average, how much do you monthly spend on tobacco products? How often does anyone use any sort of tobacco product inside your living place? DAILY WEEKLY MONTHLY LESS THAN MONTHLY NEVER During the past 6 months, did anyone use tobacco product in indoor areas where you work/study? YES NO During the past 12 months, have you tried to stop the use of tobacco products? YES NO Have you visited a doctor or other health care provider w.r.t use of tobacco product concerns in the past 12 months? YES NO In the last 6 months, have you noticed information about the dangers of using tobacco products

P2 A: G:

P3 A: G:

P4 A: G:

P5 A: G:

P6 A: G:

P7 A: G:

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Prevalence of Tobacco Products

or that encourages quitting, in newspapers or in magazines? YES NO

Media not accessible

In the last 6 months, have you noticed information about the dangers of using tobacco products or that encourages quitting on television? YES NO

Media not accessible

In the last 6 months, did you notice any health warnings on packings of tobacco products? YES NO DID NOT SEE ANY CIGARETTE PACKAGES In the last 6 months, have warning labels on tobacco products packings led you to think about Quitting? YES NO In the last 6 months, have you noticed any advertisements or signs promoting tobacco products in stores where tobacco products are sold? YES NO In the last 6 months, have you noticed any of the following types of tobacco product Promotions? a. Free samples of tobacco products? b. tobacco products at sale prices? c. Coupons for tobacco products? d. Free gifts or special discount offers on other products when buying tobacco products? e. Clothing or other items with a tobacco products brand name or logo? f. tobacco products promotions in the mail?.

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Prevalence of Tobacco Products Tobacco Non-user

In the last 6 months, have ever been exposed to an activity that encourages/tempts the use of tobacco products? If yes please brief on it YES NO In the last 6 months, have you noticed any advertisements or signs promoting tobacco products in stores where tobacco products are sold? YES NO

In the last 6 months, have you noticed any of the following types of tobacco product Promotions? a. Free samples of tobacco products? b. tobacco products at sale prices? c. Coupons for tobacco products? d. Free gifts or special discount offers on other products when buying tobacco products? e. Clothing or other items with a tobacco products brand name or logo? f. tobacco products promotions in the mail?.

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Prevalence of Tobacco Products

3.1 Questionnaire for rural population First page (basic information)

Exhibit 2

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Smoking tobacco (first)

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Smoking tobacco (second)

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Smokeless tobacco (first)

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Smokeless tobacco (second)

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Prevalence of Tobacco Products

Smokeless/smoking tobacco (first)

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Prevalence of Tobacco Products

Smokeless/smoking tobacco (second)

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Tobacco non-user

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