Tobacco & Its Abuse: Current Scenario AND Policies & Prevention: Current Strategies Epidemiology, GATS Survey, Prevention Policies

1. Tobacco & Its Abuse: Current Scenario
AND
Policies & Prevention: Current Strategies
Dr. Ankit Chaudhary
Resident
Community Medicine
IGMC Shimla

2. Layout
 Introduction
 History
 Types
 GATS findings
 Policies & Laws
 Himachal Scenario
 Challenges & Remedies
2

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
3

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
4

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
5

6. Tobacco Epidemic Curve 6

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
7

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
8

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
9

10. Smoke Exposure 10

11. Implications of Tobacco Use
 Health Related
 Socio Economic
 Occupational
 Environmental
11

12. Health Consequences 12

13. Socio Economic Implications 13

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
14

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
15

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
16

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.
17

18. GATS 2 findings contd... 18
Percentage of tobacco users by age group Percentage of adults using different smokeless tobacco products

19. GATS 2
findings
contd...
19

20. GATS 2 findings contd... 20

21. GATS 1 vs GATS 2
Prevalence of current tobacco use Exposure to SHS
21

22. GATS 1 vs GATS 2 contd...
Quit attempts among smokers Noticed health warning labels on packages
22

23. GATS 1 vs GATS 2 contd...
Noticed any type of cigarette, bidi &
smokeless tobacco promotion
Average monthly expenditure on
cigarette and bidi (INR)
23

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)
24

25. WHO algorithm
for tobacco
cessation contd…
25

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
26

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
27

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
28

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
29

30. MPOWER 30

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
31

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
32

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
34

35. Organizational framework 35

36. FCTC, MPOWER, & COTPA 36

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
37

38. FCTC/MPOWER Achievements 38

39. Achievements contd... 39

40. Achievements contd... 40

41. Achievements contd... 41

42. Achievements contd... 42

43. Latest Finding 43

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%
44

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
45

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)
46

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

49. Himachal Future Strategy 49

50. Himachal Future Strategy contd… 50

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
51

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
52

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
53

54. Thank You….!!!
54