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C O M M E N TA RY

Tobacco Consumption in India

D E R E K YA C H

O B A C C O is fast being recognized as a development issue as well as a public health disaster (1). Earlier this year, the European Commissionthe largest public provider of development assistance globally hosted a high level seminar that brought together new and compelling evidence showing how tobacco leads to health and economic hardship. This built on the work of the World Bank carried out during the late 1990s (2). Indias response to this development threat is well outlined by Gupta and Sankar (3). Gupta and Sankar describe the many complexities inherent in tobacco control in India: many producers responding to local demand built over decades; a wide diversity of types of tobacco use; until recently, a weak policy response by government at all levels and few vocal and effective NGOs; and most worrying, a rising prevalence of overall tobacco consumption among nearly all sub-groups of the population. Almost 182 million people in India smoke representing 17 percent of all consumers worldwide (4). Signs of progress in moving tobacco control ahead in India are emerging. In recent years epidemiologists have revised national estimates on the impact of tobacco on health and death. In 1996 it was estimated that 800 000 people died from tobacco (5) and that 150 000 cases of cancer, 4.2 million cardiovascular cases, and 3.7 million chronic respiratory disease cases were due to tobacco (6). Several studies, some comprising tens of thousands of people, have provided solid estimates on the relationship between several forms of tobacco use and multiple outcomes. Elsewhere, Gupta and Mehta

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showed from their follow-up of a Mumbai cohort of 55 000 people, that all-cause mortality relative risks for cigarette use was 1.4 and 1.8 for bidi users (7). These cohort studies compare favorably with the best available from the UK and USA. Researchers have also focused on several aspects of tobacco epidemiology rarely studied elsewhere. A strong positive association between tobacco use and tuberculosis has been documented in several Indian studies (8,9). This compliments an international review on the topic and shows that a close relationship exists between a major non-communicable disease risk and a major infectious disease cause (10). Further, the ubiquity of smokeless tobacco use has allowed some of the best estimates to be derived for the relationship between consumption and oral cancers (11). Laboratory scientists and toxicologists have shown in several studies that nicotine levels in bidi users are at least as high as in cigarette users, and probably much higher (12). This has implications for the treatment of tobacco dependence. Economists have used the cumulative impact of premature death and considerable disease caused by tobacco to estimate that the economic cost to the country was $US 6.5 billion in 1999 (13). This is probably a severe underestimate of the true gure for three main reasons: rst, treatment of many tobacco-caused diseases remains inadequate leading to lower real costs being incurred; second, the data only estimate the impact of past consumption on present health status. The authors have highlighted the fact that prevalence is increasing; recent surveys among children in many Indian states document that the male/female ratio is substantially less (1.3/1 for bidis and smokeless tobacco) then among adults (about 5/1) and suggests that there will be rapid increase in the burden of disease caused by tobacco in women over the next few years (14). The third reason $US6.5 billion constitutes an underestimate, is that the economists studied only public sector expenditures and excluded considerable private health care costs. Gupta and Sankar outline steps being taken by the Indian government, by the courts, and by NGOs to address tobacco control (15). All these steps are necessary but not sufcient. The Indian tobacco control movement still needs to address several challenges more robustly. The best assurance of progress lies in having a strong and vibrant NGO movement that will continue to advocate for laws, not merely to be passed, but to be fully implemented. NGOs and the

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media also need to be vigilant about tobacco industry pressures, usually behind the scenes, to thwart the introduction of effective control measures. Further, specic adjustments to tobacco control policies to address the diversity of forms of tobacco use, and the levels of poverty that exist among many users, are needed. It was striking to note, from Gupta and Sankars paper, a steep social class gradient for all forms of tobacco use; and further that bidi and smokeless tobacco use are more common among the poorest sectors. WHO recommendations about tobacco control were developed mainly to address cigarettes. There are few examples of success in reducing consumption of smokeless tobacco among poor populations. There are no examples of successful efforts to reduce bidi consumption. The reasons are complex: tobacco excise taxes effectively inuence consumption. But bidis and smokeless tobacco are currently taxed at very low levels to protect the poor. If taxes are to be part of a control strategy, a serious political effort will be required to focus taxes where they will discourage use. That challenge should engage the World Bank and Indian economists. If bidi taxes are kept very low, further increases in tobacco taxes may lead consumers to switch to bidis. This requires urgent study. Strong pressure from tobacco interests can be expected as bidi and smokeless tobacco excise taxes are increased. Similarly, bans on tobacco advertising and promotion, included in the new Indian Laws, will have no impact on bidi or smokeless tobacco consumption but will pre-empt future advertising of these products. The proposed ban on smoking in public places will have no effect on smokeless tobacco users and probably minimal effect on bidi consumption unless accompanied by a major educational program that effectively targets the poorest sectors of society in their work and living settings. The role of primary health care services, and traditional health care providers, could play a decisive role in reaching bidi and smokeless tobacco users, informing them about the addictiveness and harm caused by tobacco use and by providing support for them to quit. Some adaptation of the usual approaches to cigarette users may be required. When it comes to supply measures, with the exception of tackling the problems of children selling and buying tobacco products and of smuggling, it would be premature to invest heavily in tobacco diversication programs. Within the United Nations family, the World

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Health Organization (WHO) chairs an Ad Hoc Task Force on Tobacco Control that includes among its members, the IMF, UNICEF, UNESCO, FAO and the World Bank. A crucial early decision in 1999 was to put tobacco demand reduction as the rst UN tobacco policy priority. Supply measures, particularly those related to agricultural alternatives would be addressed as a consequence of reduced demand. Demand for tobacco is extremely high in India. And being met by poor farmers. A long-term perspective is needed that starts by investing now in research aimed at identifying alternative higher wage jobs for poor rural farmers. Tobacco diversication needs to be linked to rural development a point stressed several times during the EC Seminar on tobacco and development (16). Lessons from countries as diverse as Brazil, South Africa, Poland, and Thailand, suggest that when there is political support for tobacco control from the political leadership of a country, and it is supported by solid in-country research, and an open and transparent media, progress will happen (17). These ingredients are now in place in India. The countrys leadership role during the Framework Convention on Tobacco Control negotiations being one recent example. The FCTC provides a global response to the global reach and efforts of the tobacco industry to seek out new markets, especially where the regulatory environment is weakest (18). We can expect continued and hopefully intensied action against a major cause of premature death and suffering in India.
REFERENCES 1. World Health Organization. Tobacco and health in the developing world. Background paper for the High Level Round Table on Tobacco Control and Development Policy, Brussels, 34 February 2003. 2. World Bank. Curbing the epidemic: Governments and the Economics of Tobacco Control. World Bank 1999, Washington 3. Gupta I., Sankar D. Tobacco consumption in India: a new look using data from the National Sample Survey. Journal of Public Health Policy, 2003; 24: 233245. 4. Shimkhada R., Peabody J.W. Tobacco Control in India. WHO Bulletin 2003; 81: 4852. 5. NSSO (1998). Sarvekshana, National Sample Survey Organization. Department of Statistics, Ministry of Planning, Government of India, JanuaryMarch 1998: p76.

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6. CMR. Tobacco Plain Facts (1996). Division of Noncommunicable Diseases, Indian Council of Medical Research, New Delhi, India, 1996. 7. Gupta P.C., Mehta J.C. Cohort study of all-cause mortality among tobacco users in Mumbai, India. WHO Bulletin 2000: 78 (7): 87783. 8. Kolappan C, ; Gopi P-G. Tobacco smoking and pulmonary tuberculosis. Thorax 2002; 57: 964966. 9. Gajalakshmi V, Peto R, Kanaka TS, Jha P. Smoking and mortality from tuberculosis and other diseases in India. The Lancet 2003; 363:507515 10. Yach D. Partnering for better lung health: improving tobacco and tuberculosis control. International Journal Tuberculosis Lung Diseases 2000; 4(8): 693697. 11. Critchley J.A. Unal B. Health effects associated with smoking tobacco: a systematic review. Thorax 2003; 58: 435443. 12. Malson J.L., Sims, K., Murty R., Pickworth W.B. Comparison of the nicotine content of tobacco used in bidis and conventional cigarettes. Tobacco Control 2001; 10: 181183. 13. Chaudhry K.., Prabhakar A.K., Prabhakran P.S., Singh K., et al. Prevalance of tobacco use in Karnataka and Uttar Pradesh. Final report of the study by the Indian Council of Medical Research and World Health Organization, SEARO, 2002. 14. Global Youth Tobacco Survey Collaborating Group. Differences in Worldwide tobacco use by gender: ndings from the global youth tobacco survey. Journal School Health 2003; 73(6): 207215. 15. Gupta I., Sankar D. Tobacco consumption in India: a new look using data from the National Sample Survey. Journal of Public Health Policy, 2003; 24: 233245. 16. World Health Organization. Tobacco and health in the developing world. Background paper for the High Level Round Table on Tobacco Control and Development Policy, Brussels, 34 February 2003. 17. Tobacco control policy. Strategies, successes and set backs. de Beyer J and Brigden L.W. (editors). World Bank and Research for International Tabacco Control. Washington, 2003. 18. Yach D., Bettcher D. Globalization of tobacco industry inuence and new global responses. Tobacco Control 2000; 9(2): 206216.