3. Introduction
Legal drug: kills its best customers; Kills > AIDS, RTAs, murder & suicide combined
Leading single preventable cause of deaths worldwide
≈ 7 million deaths/yr attributed to tobacco; ≈ 890 000 due to non-smokers exposed to SHS
≈ 80% of world's 1.1 billion smokers live in LMICs
India: 2nd largest tobacco producing nation & 2nd largest consumer world-wide
Every 10th adult (10.7%; 99.5 million) in India currently smokes tobacco
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4. History
Religious rituals, Medicinal use, Recreational habit
Dates back to 5000 BC in shamanistic rituals
Smoking of tobacco was used to achieve trance & to come into contact with spirit world
Fumigation (dhupa) & fire offerings (homa) prescribed in Ayurveda for medical purposes
Dhumrapana ("drinking smoke"), has been practiced for at least 2,000 years
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5. History contd...
Tobacco cultivated first around 6000 BC by Native Americans
Indigenous Americans began smoking & using tobacco enemas
In 1800s grown commercially for first time in Canada.
1913: birth of ‘Modern Cigarette’; R.J. Reynolds introduced the first commercial brand ‘Camel’
Tobacco was first introduced in 16th century in China & India
‘snuffing’ (18th century), cigars (19th century), manufactured cigarettes (20th century),
Electronic cigarettes
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7. Types
Different forms: Altered flavor, smell & pharmacological properties
However, all forms have in common delivery of nicotine to CNS
Smoked or Smokeless
smoked using cigarettes or other delivery systems like pipes, cigars and narghiles
smokeless forms, such as chewing & to be absorbed by mucosa (snuff)
Nicotine is absorbed in a similar manner and is highly addictive
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8. Smoked Tobacco
-Cured & finely cut tobacco, reconstituted, rolled into a paper with filter
-> 4,000 chemicals , 60 chemicals known to cause cancer
-Tobacco wrapped in a tendu/temburni leaf & secured with a colorful string
-↑ concentrations of nicotine, tar, & CO than conventional cigarettes , ↑ addictive
-Roll of tobacco wrapped in leaf, smoked without a filter
-More nicotine than cigarettes, nicotine dependence
-No standard composition, ↑ CO, Rebirth
-A session of 20-80 min, 50-200 drags, inhaling a total of 0.5-1.0 L of smoke
-Reusable, chamber or bowl, stem and mouthpiece; Lit
-Cause gum disease, tooth loss, cancer of oral cavity additionally
-Mixture of tobacco, cloves & additives, Indonesia
-Deliver more nicotine, CO & tar
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9. Smokeless Tobacco
-Oldest modality, Resurgence, As loose leaf, plug, or twist
-Falsely labeled to promote smoking cessation
-Direct targets: smokers experiencing withdrawal in smoke-free places
-Moist form, small sachets to be placed in the mouth
-Tobacco is mixed with water, salt and flavorings
-Lower quantities of cancerous agents
-Finely processed to dissolve in mouth, Smoke and spit free
-Varieties: strips, sticks, orbs & compressed tobacco lozenges.
-Held together by food-grade binders, look similar to a breath mint or candy
-Nicotine delivery system, Battery-powered device, cartridge, vaporized solution
-Reusable, refillable and replaceable cartridges
-Marketed as an alternative or an aid in quitting; Recent evidence carcinogenic
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14. Occupational Implications
Green tobacco sickness (GTS)
Observed among workers who cultivate and harvest tobacco
Nicotine absorbed through skin, contact with leaves of mature tobacco plant
Nausea, vomiting, headache, muscle weakness & dizziness
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15. Environmental Implications
Tobacco farming contributes to both vegetation loss and climate change
Flue-cured tobacco requires a considerable amount of wood, potential for significant deforestation
≈ 200,000 hectare land cleared/year for tobacco cultivation; soil erosion & loss of soil fertility
Chance of contamination of both superficial aquifer & deep groundwater with pesticides
Pesticides: environmental hazards, extremely toxic to fish and birds
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16. Economic burden
Economic costs of tobacco use are enormous, > US$ 1.4 trillion in health care costs
lost productivity ≈1.8% of world’s GDP & > 40% spent on school education
India 2011: economic burden attributable to tobacco use from all diseases for persons aged 35-
69 ≈ 22.4 billion USD
1.16% of GDP
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17. Global Adult Tobacco Survey 2 findings
(2016-17)
28.6% of all adults currently use tobacco (42.4% men, 14.2% women)
10.7% of all adults currently smoke tobacco (19.0% men, 2.0% women)
21.4% of all adults currently use smokeless tobacco (29.6% men, 12.8% women)
38.7% & 30.2% of adults exposed to SHS at home & workplace respectively
19.2% adults: smoking tobacco advt & 18.3% adults: smokeless tobacco advt
68.0%: anti-smoking tobacco info & 59.3%: anti-smokeless tobacco info on TV or radio
92.4% & 95.6% adults believed smoking & smokeless tobacco cause serious illness resp.
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18. GATS 2 findings contd... 18
Percentage of tobacco users by age group Percentage of adults using different smokeless tobacco products
21. GATS 1 vs GATS 2
Prevalence of current tobacco use Exposure to SHS
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22. GATS 1 vs GATS 2 contd...
Quit attempts among smokers Noticed health warning labels on packages
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23. GATS 1 vs GATS 2 contd...
Noticed any type of cigarette, bidi &
smokeless tobacco promotion
Average monthly expenditure on
cigarette and bidi (INR)
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24. WHO algorithm for tobacco cessation
Consists of assessing the tobacco habit and then going through the procedures of simple
advice, behavioral counseling and pharmaceutical treatment as per requirement
Every patient who uses tobacco should be offered a brief intervention method of 5 A′s,
ASK (about tobacco use)
ADVISE (to quit)
ASSESS (commitment and barriers to change)
ASSIST (users committed to change)
ARRANGE (follow-up to monitor progress)
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26. Partners for Tobacco Control
World Health Organisation [WHO]
Public Health Foundation of India [PHFI]
Voluntary Health Association on India [VHAI]
Campaign for Tobacco Free Kids [CTFK] & Voice of Tobacco Victims [VOTV]
World Lung Foundation [WLF]
International Union Against Tuberculosis and Lung Disease
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27. Framework on Convention on Tobacco Control
World’s first global public health treaty
Adopted by 56th WHA on May 21, 2003, Entered into force in February 2005
Establishes mechanisms to control use & proliferation of tobacco
India became a signatory on 10th September 2003
Objective:
To protect present/future generations from devastating health, social, environmental &
economic consequences of tobacco consumption and exposure to tobacco smoke by
providing a framework for tobacco control measures to be implemented by Parties at
national, regional & international levels in order to reduce continually & substantially the
prevalence of tobacco use & exposure to tobacco smoke
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28. Framework on Convention on Tobacco Control
contd...
Guiding principles
Every person should be informed of health consequences, addictive nature & mortal threat posed by tobacco
consumption & exposure to tobacco smoke
Strong political commitment is necessary to develop/support comprehensive multi-sectoral measures & responses
Participation of civil society is essential in achieving the objective of the Convention & its protocols
International cooperation is necessary to establish & implement effective TCP
Comprehensive multi-sectoral measures are essential to ↓ consumption of all tobacco products-Px premature
disability & mortality
Issues relating to liability, as determined by each Party within its jurisdiction are important part of comprehensive
tobacco control
Importance of technical & financial assistance to aid economic transition of tobacco growers/workers whose
livelihoods are seriously affected as a consequence of TCPs should be recognized & addressed in context of nationally
developed strategies
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29. Framework on Convention on Tobacco Control
contd...Mitigation Measures
Demand Reduction
(Article 6-14)
Price and tax measures
Non-price measures
– Protection from exposure to
smoke
– Regulation of contents of
products
– Regulation of product disclosures
– Packaging & labeling of products
– Education, communication,
training public awareness
– Advertising, promotion &
sponsorship
– Measures concerning tobacco
dependence & cessation
Supply Reduction
(Article 15-17)
Control Illicit trade in
tobacco products
Control sales to & by minors
Provision of support for
economically viable
alternative activities
Other Measures
(Article 18-38)
Protection of environment & health of
persons
Research, surveillance & exchange of
info
Reporting & exchange of info
Cooperation in the scientific,
technical, legal fields and provision of
related expertise
Conference of Parties
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31. Cigarettes & other tobacco products (prohibition of
advertisement and regulation of trade & commerce, production,
supply and distribution) Act, 2003 (COTPA)
To prohibit and regulate tobacco use in India
Sections & sub-sections; Revised & amended periodically
Intended to
protect & promote public health
encompass evidence based strategies to reduce tobacco consumption
to curb smoking in public places
impose penalties to violators
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32. COTPA contd...
Section 4: Prohibition of smoking in public places
Section 5: Prohibition of direct/indirect advt, promotion & sponsorship of cigarette & other products
Section 6(a): Prohibition of sale of cigarette & other tobacco products to < 18 years
Section 6(b): Prohibition of sale of tobacco products within 100 yards of educational institutions
Section 7: Mandatory depiction of statutory warning on tobacco packs
Section 7(5): Display of tar & nicotine contents on tobacco packs
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33. COTPA contd... Recent Amendments 33
w.e.f. 01.09.2018 w.e.f. 01.09.2019
One Common Warning
34. National Tobacco Control Programme
(2007)
NTCC (MoHFW): Policy formulation, planning, implementation, M&E
Objectives
To bring about greater awareness about harmful effects of tobacco use & about Tobacco Control Laws
To facilitate effective implementation of Tobacco Control Laws
Thrust areas
Training of health & social workers, NGOs, school teachers, enforcement officers etc.
IEC activities, School Programmes
Monitoring tobacco control laws
Co-ordination with PRIs for village level activities
Setting-up & strengthening of cessation facilities including pharmacological Rx facilities at distt level
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37. Sustainable Development Goals
3.4 Reduce by one third premature
mortality from NCDs by 2030
3.a Strengthen implementation of WHO
FCTC in all countries, as appropriate
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44. Cost-effectiveness of tobacco control policies
Overall tax increases is ↑ cost-effective relative to other health interventions (Ranson et al)
10% ↑ in cigarette prices → 2.5–5% ↓ in demand in HICs
10% ↑ prices → ↓ smoking by about 4% in HICs and by about 8% in LMICs
10% ↑ in bidi prices could ↓ rural bidi consumption by 9.2%
10% ↑ in cigarette prices could ↓ rural cigarette consumption by 3.4%
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45. Cost-effectiveness of tobacco control policies
Higher cigarette prices may not necessarily encourage quitting and
May only divert cigarette smokers to other tobacco products (A study from vietnam)
However, it is expected that increases in tobacco taxes reduce tobacco use by
Preventing initiation
Increasing the likelihood of cessation among current users
Reducing relapse among former users
Reducing consumption among continuing users
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46. Himachal Scenario
Prevalence of any tobacco use: GATS-2 16.1% (vs 21.2 % GATS-1); ↓ 5%
GATS-2: 13% smokers, 1.9% smokeless tobacco users & 1.2% use both types of tobacco
GATS-1 vs GATS-2: ↓ in prevalence of smoking by 4.1% & smokeless tobacco use by 1.4%
Tobacco use: 30.4% males & 1.7 females
Smoking: 26.7% males & 1.6% females
Smokeless tobacco: 6.1% males & 0.1 females use
Bidi MC (12.6% of adults smoke bidi, while 2.8% Cigarette & 2.6% Khaini)
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47. Tobacco Use: Himachal vs India (%) 47
10.7
21.4
28.6
14.2
3.1
16.1
0
5
10
15
20
25
30
35
Tobacco Smoke SLT All Tobacco Use
India Himachal
48. Himachal Tobacco Control Strategy 48
Shimla: 4th smoke free city (2010); State declared smoke free (2013)
National Tobacco Control Program implemented in Shimla in 2013
Tobacco cessation facilities in all DHs (de-addiction centres)
Ban: Smoking in public places, Sale to/by minors, Edu. institutes, Sale without warning, Advt
Ban on loose cigarette/beedi/tobacco
Vendors should be licensed
Violations to health/police personnel
51. Challenges
Implementation remains a challenge due to lack of trained enforcement squad
Involvement of police force still not uniformly possible as COTPA violations remains low priority
Local municipal bodies are not motivated equally across States to take up relevant actions
Surrogate advertisements by the Tobacco Industry undermines the efforts
Tobacco Industry often raises some livelihood issues of the bidi workers
Lucrative advance purchase of crops, soft loans & other incentives trap tobacco growers
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52. Recipe for Success
Advocacy for political and administrative will
Devising an effective multi-sectoral coordination: tobacco control is beyond health deptt
Effective media management
Effective implementation of NTCP across nation; Integration with NPCDCS
Provision of better manpower, legal & infrastructural support; online reporting & monitoring
Strengthening Toll free helpline no. 1800110456 for dissemination of info relating to violations
Setting up Cessation Centres as well as a quit helpline at the national level for tobacco users
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53. References
Global Adult Tobacco Survey Fact Sheet India 2016-17
WHO Framework Convention On Tobacco Control
WHO Report On The Global Tobacco Epidemic, 2017 Monitoring tobacco use and prevention
policies
MPOWER In Action: Defeating the global tobacco epidemic
National Tobacco Control Programme, MoHFW India
Cigarettes & other tobacco products (prohibition of advertisement and regulation of trade &
commerce, production, supply, and distribution) Act, 2003 (COTPA)
Report on Economic Burden of Tobacco Related Diseases in India, PHFI
WHO Tobacco Atlas
Himachal displays sixth highest decline in tobacco use, Statesman
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